Papers 1 - 4

lASH 1999, Vol. 24, No.3, 162-173

copyright 1999 by The Association for Persons with Severe Handicaps

Early Intervention for Young Children with Autism: Continuum-Based

Behavioral Models Stephen R. Anderson

Summit Educational Resources

Raymond G. Romanczyk State University of New York-Binghamton

Over the last three decades, instructional methods de- rived from applied behavior analysis (ABA) have shown considerable promise for many young children with au- tism. The ABA approach establishes a priori that assess- ment and intervention methods must be based on gener- ally accepted rules of scientific evidence. On one hand, the approach has produced a rich resource of conceptu- ally consistent and scientifically validated techniques that can be applied in various combinations across many dif- ferent contexts. On the other hand, this diversity has re- sulted in some confusion regarding the precise charac- teristics of ABA. In this article, the authors first describe many of the common programmatic and methodologic elements that form the foundation of the approach. A summary of the scope of the behavioral research is pro- vided including greater detail on six studies that demon- strated large-scale interventions. Finally, the authors de- scribe components of program models that share com- mon elements of the ABA approach and use a broad continuum of traditional behavioral techniques. Some specific myths about the approach are simultaneously addressed.

DESCRIPTORS: applied behavior analysis, inter- vention methods, program models, autism

Autism is a serious developmental disability that pro- vides a complex challenge for parents, professionals, and all those who come in contact with the child. Au- tism is a syndrome, as opposed to a disease entity, that is characterized by specific behavioral patterns and characteristics. A complex disorder (Berkell Zager, 1999; Cohen & Volkmar, 1997; Matson, 1994; Roman- czyk, 1994; Schopler & Mesibov, 1988), autism spec- trum disorder (ASD) has been studied for 50 years, yet

Address all correspondence and reprint requests for re- prints to Stephen R. Anderson, Summit Educational Re- sources, 300 Fries Road, Tonawanda, NY 14150-8897. E-mail: [email protected]

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still results in controversy, misinformation, and is a source of great confusion for parents attempting to make treatment and education decisions for their chil- dren. For the purposes of this article, we assume that the reader is familiar with the difficult and complex issues of obtaining an accurate differential diagnosis for young children, as well as with the critical process of obtaining an assessment of the child's development (Harris & Handleman, 1994; New York State Depart- ment of Health, 1999a; Powers & Handleman, 1984; Romanczyk, Lockshin, & Navalta, 1994; Schopler & Mesibov, 1988).

A general historical reading in the field of autism quickly results in the impression that autism is a severe disability for which little evidence is found for long- term positive outcome, that it is difficult to diagnose, and that incidence and prevalence figures are contro- versial (California Department of Developmental Ser- vices, 1999). Autism is also strongly associated with a great number of "fads" and "movements" that over the last several decades have promised much, but consis- tently have failed to deliver when the harsh light of objective evaluation is focused on supposed break- through procedures (Delmolino & Romanczyk, 1995; Green, 1996a; Olley & Gutentag, 1999; Smith, 1996). Often "models" are promulgated with little empirical support, but with a wealth of sincerity and enthusiasm. By studying this history, an appreciation is formed for the complexities of generating a viable model that stands the test of time and objective evaluation.

It is in this context that we first describe an approach that establishes a priori that the selection of assessment and intervention approaches must be based on gener- ally accepted rules of scientific evidence for efficacy. It is a "bottom up" approach, in that principles and pro- cedures with demonstrated efficacy are assembled into a coherent model that is again subjected to empirical validation. This is quite different from the process of developing a conceptual model and then seeking to find confirmatory evidence.

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To date, only one nonmedical approach meets the boundary conditions of this model as applied to autism. This approach has consistently produced outcomes that are reproducible, describable in precise terms, are tied to a conceptualization that has strong and extensive experimental support, and uses, as a necessary compo- nent, continuing objective evaluation. This approach, known as applied behavior analysis (ABA) in the con- text of autism, but more generically as behavior therapy or the behavioral approach, was first applied in the treatment of autism more than three decades ago. Its roots are strongly within a research/academic frame- work, and it has been applied with empirically evalu- ated success to a wide array of human problems (Bar- low, 1988; Barlow, Hayes, & Nelson, 1984; Spiegler & Guevremont, 1993). Interestingly, perhaps because of its focus on objective evaluation rather than on consen- sus of opinion, it has not become popularized and has often been grossly misunderstood (cf. Maurice, 1993).

Over the past three decades, systematic research in- vestigations have demonstrated the utility of specific components of ABA. More recently, larger scale out- come studies again have consistently demonstrated that significant impact can be made for children with autism (New York State Health Department, 1999a). For those who are influenced by research versus anecdotal reports, there exists a growing and diverse behavioral technology that can be applied. One unexpected out- come of this extensiveness has been a clustering of be- havior analysts into several schools with strongly held positions. In our opinion, these are divisions based largely on emphasis on one particular instructional technique or another, a grouping of techniques in a certain clustering, or differences in the strategy of ser- vice delivery. However, all fall within the rubric of ABA. It is our opinion that no single technique nor collection of techniques can be correct (or effective) for every person in every situation. Thus, the data based feedback loop in ABA is inherently a self-correcting mechanism if applied in the context of clinical decision making. It is our goal in this article to first outline the common programmatic and methodologic elements of the ABA approach. We discuss some of the features that seem to define typical behavioral models and within this context respond to the many myths that have arisen regarding ABA.

Programmatic Common Elements

It is probably accurate to state that many models, behavioral analytic and nonbehavioral analytic, share some common programmatic elements. Dawson and Osterling (1997) reviewed a number of programs for children with autism that met the boundary condition of having published detailed descriptions of the pro- grams and provided intake and outcome data (many are reviewed in this special issue of JASH). They pre-

sent a series of common elements that were observed that are considered tried and true. More precisely, by examining common elements that exist across programs that differ significantly in approach, the authors state that these programmatic common elements are "un- likely to reflect an idiosyncratic viewpoint or one inves- tigator's philosophical attitude" (p. 314). These pro- grammatic common elements are specific curriculum content, highly supportive teaching environments and generalization strategies, predictable routine, func- tional approach to problem behaviors, planned transi- tion, and family involvement.

These programmatic common elements perhaps re- flect the minimum starting point for program develop- ment, along with appropriately trained and caring staff, adequate resources, and supervisory and review mecha- nisms. Given these as "basics," then the task is to utilize a methodology that allows each of these elements to be addressed in an individualized manner, for children, family, and staff. It is at the point of selecting specific methodology for instruction that behavioral and non- behavioral models sometimes begin to diverge.

Methodologic Common Elements

There are methodologic common elements within the behavioral approach. First, the approach views be- havior as functional and purposeful, even when func- tion and purpose are not immediately discernible by an observer. Behavior is viewed as the result of a complex blend of variables that include the individual's strengths and limitations, physical status, history, and the current social-environmental circumstances (Romanczyk & Matthews, 1998). As with many complex approaches, there are often subtle differences between specific methodologies and theories that are associated with the approach. With respect to autism, ABA is a specific form of the more general behavioral model.

Analysis and Measurement ABA places stress on understanding the behavior in

question, whether it is the acquisition of a skill that is currently absent in a person's repertoire or the amelio- ration of a problem behavior. If emphasis is placed on the analysis level, then it follows that there need to be certain prerequisite steps.

The first of these prerequisites is the objective mea- surement of behavior. Most measurement systems have technical pros and cons, as well as practical cost effec- tiveness parameters. There is a large body of literature within the field of science in general and psychology specifically that indicates human observers are prone to a number of very specific errors in conducting obser- vations. We are all subject to influences and biases that limit our objectivity. One credible reason for this diffi-

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164 Anderson and Romanczyk

culty in objective measurement is that one of our strengths with respect to information processing is the ability to detect patterns. However, as with all systems, our ability to detect patterns is not perfect. We are able to perceive specific patterns where, in fact, none exists. We can be differentially influenced by information, context, and experience that have emotional as well as informational content.

Often in clinical and educational service delivery, we violate this basic principle of objectivity so that the in- dividuals performing assessment, delivering services, and evaluating outcome are one and the same. It is important to stress that the influences that limit our ability to make objective observations are not primarily based on such factors as sophistication, education, fal- sification, intentional bias, and deception. Rather, they are based on an information processing limitation that all humans share. By understanding these processes, we can guard against potentially inaccurate observations and conclusions. Thus, the sine qua non of the applied behavior analytic approach is that objective measures are taken of the individual's behavior and that these measures must meet the boundary conditions of being operationally defined, reliable, and valid.

Operational definitions simply translate the normal colloquial reference that we give to certain behaviors into more objectively defined observational terms. A good example would be attempting to assess a child who is "anxious." This is a term that most individuals would recognize and believe that they have an under- standing of what it means. Difficulty arises with respect to precision and the application of such terms to spe- cific individuals. For example, with anxiety, one could view it as a construct, the summation of a number of different factors that are assumed to be coherent. We can divide the imprecise construct of anxiety into a number of components: cognition, self-report, overt be- havior, performance, and physiologic.

Although anxiety is a useful term for the purpose of communication concerning a problem the individual is experiencing, from a behavioral perspective it would be further defined within the above categories. This allows highly individualized assessment for a given person as to how specifically anxiety is manifested for the indi- vidual. ABA emphasizes addressing the specific, unique expression of behavior by the individual.

Reliable observations refer to the degree to which the various specific behavioral observations conducted by different observers are in agreement. This is typi- cally done by having two independent observers per- form observations and then compare very precisely the degree to which they agree and disagree on the specific temporal pattern of the behaviors observed. To be in- dependent, individuals should not be given specific ex- pectations such as "medication is being considered," or "we are seeing problems with rising anxiety," or "it's clear he's anxious and we need to document that." Op-

erationalized, unbiased, and reliable observation serves as the basis for hypothesis testing as to factors that may be of importance and influence the individual, and thus leads to the process of conducting a functional analysis (a point to be discussed next).

Assessing the Child Assessment is a crucial component of any clinical/

educational model. Because there are as many differ- ences between young children with autism as similari- ties among them, assessment must be a constant focus point when developing and implementing a compre- hensive intervention program. Traditional assessment methods such as the administration of standardized psychological, speech, and achievement tests, "survey" assessments such as rating scales, and behavioral assess- ment all have relative strengths and weaknesses.

Within the practice of ABA, there are various sub- components of assessment. First, assessment of an in- dividual with autism, particularly a young child, can be a very difficult task. While assessment is often some- what arbitrarily divided into standardized psychometric evaluation, social history/family status assessment, in- formal observation, and much more rarely, functional assessment, ABA focuses strongly on functional assess- ment (functional analysis). It is not and should not be seen as incompatible with the assessment methods mentioned above. For example, standardized assess- ment, if feasible and properly conducted, provides im- portant information. Such assessment allows the estab- lishment of a "marker" as to the current repertoire of the child with respect to various developmental do- mains and allows a comparison to other individuals, as well as relative strengths and weaknesses within the individual. It also serves as a standardized format to assess the ability to interact in a social manner with respect to the various directions and demands and in- terchanges that occur during standardized assessment. Standardized assessment, however, is not necessarily directly useful in the selection of specific, immediate, short-term goals. Nor is it typically useful in determin- ing the specific intervention methodology that will be utilized. It is beyond the scope of this article to examine in detail the various aspects of the assessment process. We focus on that aspect most specific to the behavioral model, that of functional analysis.

Functional analysis is an often misunderstood term, partly because different disciplines have varying defini- tions. Within ABA, functional analysis is the process of ascertaining empirically the controlling variables that enhance or inhibit the expression of a behavior. It is not done by observation, filling out a behavior checklist or scale, nor by consensus among involved parties. Rather, these sources of information are used to form hypoth- eses as to what factors may be involved, and then to test these hypotheses (Iwata, Vollmer, Zarcone, & Rod- gers, 1993; Miltenberger, 1998). It is a process of ob-

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serving, hypothesizing, testing, evaluating, refining hy- potheses, and repeating.

The essential aspect of functional analysis is the ex- plicit testing of factors presumed to be important, and to conduct the testing in a manner that has the potential to clearly disprove the hypothesis. There are many uses for this very powerful methodology beyond under- standing problem behaviors, and it is particularly useful for assessment of children without verbal language. While it is often technically difficult and time consum- ing to perform, the accuracy of the information ob- tained through functional analysis and its direct appli- cability to intervention make it a most important com- ponent of ABA.

Developing an Individualized Curriculum The word curriculum has various connotations and

meanings for various professionals. In the context of this article, curriculum means a sequence of goals: (1) organized from both the long-term and short-term per- spective' (2) resulting from focused assessment, (3) re- flecting the collective priorities of involved adults, and (4) tempered by the current developmental level of child.

Because this should be an interactive process, and typically involves individuals at various levels of exper- tise, it is useful to have an outline or document that serves as a map (Romanczyk, 1996). However, caution must be expressed in that a curriculum should not be seen as a specific sequence of learning and skill activi- ties that all children will progress through in a sequen- tial manner.

One of the important characteristics of children with autism is uneven learning ability and skill levels. Thus, individualization of intervention cannot be overstated. While generally an excellent starting point, it is not necessarily most effective to teach all skills in a "typi- cally developing" sequence. Use of a curriculum must occur within a very tight feedback loop that assesses not only the logic and priority of a goal and its subcompo- nents, but also its interaction with assessment informa- tion which includes a child's current repertoire, moti- vation, and preferences. A good curriculum should have a conceptual structure (we suggest a developmen- tal sequence), offer great detail (operalization), and be used in a child specific manner (nonlinear branching).

Selecting and Systematically Using Reinforcers It is a truism concerning human behavior that moti-

vation is an important component of learning and main- taining skills. Motivation can come from a number of sources. For most individuals, this diversity provides a rich context for acquiring and maintaining skills. It is also the case that some individuals, such as children with autism, have impairment in motivation. At times, motivation may be quite idiosyncratic and limited in its extensiveness. An example would be children who are

not motivated by social attention and praise, physical contact, and the sense of accomplishment for complet- ing a task or solving a problem. Rather, these individu- als might find their own repetitive and stereotyped be- havior more interesting and enjoyable, and thus engage in it disproportionately compared to prosocial behav- ior. The term reinforcer describes a functional relation- ship that is empirical in nature, not speculative. This is a critical aspect of the behavioral model: procedural or technique components are not to be used in isolation, detached from the critical process of ongoing assess- ment. The stereotyped and incorrect reinforcement procedure "for children with autism who fail to make eye contact, each time they look at you, reinforce them with a fruit loop," is completely erroneous and misses the point entirely. Also erroneous would be the con- clusion that "eye contact is not getting better even though we keep reinforcing them with fruit loops." Even at its most basic level, ABA is intimately tied to continuous assessment of the individual and not simply the application of misperceived standard techniques.

Promoting Generalization Generalization is a key concept. It is often viewed as

the degree to which a behavior or skill learned under particular conditions and settings will be expressed in other conditions and settings. An example might be taking piano lessons and being able to perform a par- ticular musical piece quite adequately at home with the piano teacher, and then being asked to present that same piece during a recital where performance may be observed to be significantly impaired.

From the inception of ABA, generalization has been a focal concept that is bound directly to goal selection, teaching, and evaluation of behavior. In their classic article that appeared in the first issue of the Journal of Applied Behavior Analysis, Baer, Wolf, & Risley (1968) stated that generalization is a central component of ABA and that " ... generalization should be pro- grammed, rather than expected or lamented" (p. 97). That is, an important characteristic of ABA is that the intervention process must explicitly address strategies and procedures to teach and promote generalization across time, setting, people, and tasks.

There is an extensive generalization methodology to be found in the published literature. It involves knowl- edge of stimulus control, stimulus generalization, rein- forcement schedules, prompt hierarchies and fading, setting events, antecedent conditions, response variabil- ity, contingency criteria, use of multiple exemplars, set- tings, people, and contexts, as well as task analysis and response repertoire assembly. Because generalization can be problematic for certain individuals, and given the complex factors that influence generalization, a spe- cific and detailed plan for generalization should be a part of all intervention programs.

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Selecting Intervention Techniques With Documented Effectiveness

From a clinical perspective, selection of intervention techniques has two components. The first is to ascertain controlled research evidence concerning specific skills, behaviors, or conditions for individuals with a similar diagnosis/characteristics that appear in peer reviewed journals and that meet generally accepted criteria for well controlled clinical studies. Anecdotes, case studies, "expert opinions," theoretical arguments, and appeals to "clinical experience" are not acceptable substitutes. Such sources can provide potentially useful information in order to test hypotheses about effectiveness compari- son of different approaches and procedures in a re- search context, but should not be used as a substitute for controlled research evidence for clinical practice.

Second, the selected intervention must meet the boundary conditions of the original research param- eters. Sadly, interventions are often implemented in name only, that is, terms are used to label what is being offered, but the specifics of the intervention as actually applied are not consistent with the specifics of the origi- nal intervention research. Procedural integrity is mea- sured and evaluated as is the objective evaluation of the child's progress. Specifically, an evaluative process known as single subject methodology is employed (Bar- low et aI., 1984; Hersen & Barlow 1981; Sidman, 1988).

There are many very powerful tools currently avail- able to parents, educators, and clinicians who wish to avail themselves of the empirical literature. One cau- tion that should be raised is that it is essential in this process to read and review research reports in their original form, rather than as summaries. In particular, the explosion of information on the internet has suf- fered greatly by misrepresentation and inaccuracy. In- formation is often "packaged" to provide noncritical support for a particular point of view. In reading the original research report, one is able to ascertain the specific characteristics of the children who participated, the specifics of the procedures utilized, the adequacy of the research design, and the degree and magnitude of the outcomes. Certainly, it is possible to have a research study that demonstrates a significant statistical differ- ence between intervention procedures, but that does not necessarily mean that this significant difference rises to the level of clinical significance. We require both statistical significance and substantial change in the child's cognitive, social, and family and community life.

The task of reviewing such research can seem daunt- ing. Because ABA is based on basic principles of hu- man behavior, there is a wealth of research available. The published literature of professional journals was searched for research studies concerning applied be- havior analysis and autism (Palmieri, Valluripalli, Arn- stein, & Romanczyk, 1998). Given the varying termi- nology, there are about 19,000 published articles if one

uses applied behavior analysis and its synonyms. While not all this literature is directly relevant to ABA as an intervention for autism, it underscores the vast base of research that serves as the foundation for the ABA approach and its broad applicability to a wide range of populations, skills, and behaviors.

Five hundred articles specific to both ABA and au- tism were found. If we narrow the focus to research with young children with autism, conducted after 1980, and employ a single subject research methodology, ap- proximately 90 published research studies were identi- fied. These provide support for a broad continuum of behavioral techniques that focus on the development of skills in social, cognitive, self-help, independence, emo- tion, language, self-control, attachment, recreation, and academic areas.

In short, there is a large base of research literature that addresses specific populations, ages, characteris- tics, and specific educational, clinical, social, and physi- cal emphases, as well as a substantial base of research specific to ABA and young children with autism. A full review of these articles is not possible here (for exten- sive reviews, see Matson, Benavidez, Compton, Paclaw- skyj, & Baglio, 1996; New York State Department of Health, 1999b). However, there are several large-scale studies that base their conceptualization and proce- dures on the large research base, which we will briefly review. They represent the important endeavor of con- ducting controlled clinical trials.

Six studies have been published that evaluated the benefits of intensive home based intervention for chil- dren with autism. Each of these studies involved at least 1 year of intervention, included a broad range of be- havioral techniques, and evaluated its effects of a vari- ety of developmental outcomes (intellectual function- ing, language, social interactions, adaptive functioning). The most comprehensive study of home based inter- vention for children with autism was published by Lovaas (1987). Lovaas assigned preschool aged chil- dren to one of two groups: an intensive treatment group that received an average of 40 hours of one-on-one treatment per week or a minimal treatment control group that received 10 hours or less per week. Each child in the experimental group was assigned several well trained therapists who worked with the child and the parents in the home for 2 or more years. Pretreat- ment measures revealed no significant differences be- tween the treatment and control groups. However, posttreatment data indicated that 9 of 19 (47%) chil- dren in the experimental group recovered. These chil- dren were reported to have achieved normal intellec- tual and educational functioning in the first grade. In contrast, only 20/0 of the children in the control group met this criterion. A follow-up study was conducted when these children reached a mean of age 13 years (McEachin, Smith, & Lovaas, 1993). Evaluation was done by clinicians blind to the children's prior history

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and intermixed with children who had no history of developmental or psychological disturbance. At this point, 8 of the 9 recovered children were still indistin- guishable from the comparison group.

Several other investigators (Birnbrauer & Leach, 1993; Sheinkopf & Siegel, 1998; Smith, Eikeseth, Klevstrand, & Lovaas, 1997) have partially replicated the intensive behavioral intervention model described by Lovaas. In each case, there were important devia- tions from the model including the fact that all of these studies provided fewer hours per week (18 to 30 hours rather than the 40 hours provided by Lovaas). In each of these studies, children who received the behavioral interventions showed greater improvement than chil- dren in the control groups who received either less in- tervention or another type of intervention. A sixth study by Anderson, Avery, DiPietro, Edwards, and Christian (1987) appears to support these findings as well, but did not include a control group of comparable children receiving an alternative approach.

The results of these group studies when merged with the results of single subject research methods offer con- siderable support for the positive effects of intensive behavioral interventions for young children with au- tism. Nevertheless, many questions remain. As Green (1996b) pointed out, it is still unclear what variables are critical to intervention intensity (number of hours, length of the intervention, proportion of one-to-one to group instruction) and what are the expected outcomes when intervention intensity varies. It is also unclear what particular behavioral techniques (discrete trials, incidental teaching, pivotal response training) are most likely to be successful for a given child and in what proportions particular techniques should be used. The current research is limited in that it does not allow us to draw comparisons across studies. At this point, we can conclude that the best outcomes have occurred when the children received at least 30 hours of behavioral intervention.

Continuum-Based Behavioral Models

Since the publication of Let Me Hear Your Voice by Catherine Maurice (1993), requests for ABA services has grown rapidly. Parents, armed with empirical stud- ies, often approach local gatekeepers of special educa- tion services by strongly advocating for ABA. The re- quests have challenged local capacity to provide quali- fied personnel and to meet the extraordinary demand for the number of hours recommended. These issues are exacerbated by resistance from some key officials, sometimes based on inaccurate, but strongly held be- liefs about behavioral interventions.

Contrary to the beliefs of some, ABA is not a stag- nate, single continuum of prescribed methods. It em- phasizes the use of methods that change behavior in systematic and measurable ways. The unique contribu-

tion of this approach is its insistence on analysis, repli- cation, social importance, and accountability (Baer et al., 1968; Sulzar-Azaroff & Mayer, 1991). Arguably, any intervention strategy could be studied and embraced by behavior analysts, if it can be described in precise terms, reproduced, and demonstrated to be effective. At this point, ABA is an emerging technology that has consistently produced the best outcomes for children with autism. It will continue to expand its benefit to children with autism if it maintains its commitment to studying changes in behavior in systematic and measur- able ways. At the same time, it is important to remain abreast of developments outside the behavioral com- munity in biology, medicine, and neuroscience that may provide a clue to more effective interventions. It is pos- sible that a combination of behavioral and other inter- vention strategies might eventually maximize outcomes for some children with autism. For example, it has been empirically demonstrated that behavioral interventions and medications are more effective when combined than either is alone for many children with attention deficit hyperactivity disorder (Pelham, 1989; Pelham & Murphy, 1986). In short, ABA includes a large number of conceptually consistent techniques that can be used in various combinations across many different contexts.

This diversity of procedural techniques has created some confusion regarding the precise characteristics of quality ABA programs and the limits of its applicabil- ity. It has sometimes polarized practitioners who be- lieve one particular combination of behavioral tech- niques is more effective than another for all children concerned. Compounding the problem are inexperi- enced professionals who often apply a very narrow, rigid range of behavioral techniques to very complex situations. Parents, administrators, and other profes- sionals have been left to wade through a myriad of options, often without sufficient information and tech- nical ability to evaluate quality. These issues combined with historical misrepresentations have created many myths about the approach.

There are program models that share the common elements of ABA described earlier and appear to uti- lize a broad continuum of traditional behavioral tech- niques (e.g., Anderson, Campbell, & O'Mally Cannon, 1994; Handleman & Harris, 1994; McClannahan & Krantz, 1994; Romanczyk et al., 1994). It is our sense that these types of behavioral programs draw from the large base of research studies specifically addressing the young child with autism (approximately 90 single sub- j ect designs and six group studies) and use a range of behavioral techniques (e.g., incidental and discrete tri- als teaching) and contexts for learning (e.g., home based and integrated preschool settings). At the same time, each program is unique in that it combines tech- niques in different ways and emphasizes, more or less, one technique or another. It is impossible to describe exactly a "typical" behavioral program. Nevertheless,

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we will attempt to identify some features that seem to define (distinguish) typical models (hereinafter re- ferred to as continuum based models). We have chosen to do this while simultaneously addressing some of the myths that have developed about ABA.

Common Features of Continuum Based Models

Multiple Contexts for Learning Myth: ABA is exclusively a home based intervention

model. The most promising outcomes for children with autism have been reported by Ivar Lovaas in his semi- nal 1987 paper (described earlier). That study when taken in combination with the partial replications (Anderson et al., 1987; Birnbrauer & Leach, 1993; Sheinkopf & Siegel, 1998; Smith et aI., 1997) provides the most detailed description of multiyear behavioral interventions for children with autism. One common element of all of these studies is that most interventions occurred in the child's home with a later transition to school. Particularly when addressing the needs of very young children, compelling arguments can be made for providing services in the home: (1) it is a familiar and comfortable setting for the child, (2) it encourages ac- tive parent involvement, and (3) it is a natural context for learning many skills (e.g., self-help, independent play skills). However, until there are direct compari- sons, the strongest statement we can make is that the best outcomes for children with autism have been re- ported by programs employing a significant period of home based intervention. On the other hand, many of the elements commonly found in home based programs also can be found in school programs that use similar methods (i.e., highly structured environments, careful analysis and measurement of progress, functional as- sessment, individualized curricula, planned use of rein- forcers, active programming of generalization, and the use of intervention techniques with documented effec- tiveness).

Several studies have documented outcomes for chil- dren served in comprehensive center based programs using ABA methods. In one study, Fenske, Zalenski, Krantz, and McClannahan (1985) reported treatment outcomes for a group of children who received inten- sive behavioral programming in a school setting. Al- though the study had some design limitations, the re- sults indicated that children were more likely to achieve positive outcomes (regular school placement) if they enrolled in the program before age 60 months and par- ticipated at least 24 months. Another study by Harris, Handleman, Gordon, Kristoff, and Fuentes (1991) pro- vided intensive behavioral intervention in a special or inclusive classroom. Changes in intellectual and lan- guage functioning were evaluated after about 1 year of participation. On posttesting, the children with autism achieved significant improvement in their ability as measured by formal testing.

Since children spend most of their waking hours at home with their families, it makes sense to provide most initial training in their home with active parent involvement. Although not all families are willing and able to participate in a home based program, there is no reason to suspect that quality behavioral interventions applied at school would have significantly different out- comes, particularly if attention was given to the issues of generalization and parent involvement.

In summary, home and school approaches are all found in continuum based models for children with au- tism. It is also common to find combinations of home and school approaches in which the child progresses gradually from a home program to a school program (Anderson, et aI., 1994) over several months. Other models are even more flexible and the child and staff move continually and do not occupy self-contained classrooms (McClannahan & Krantz, 1994).

Progression From Individual to Group Instruction Myth: ABA always is characterized by one-to-one

intervention. Although many behavioral models have emphasized the need for intensive one-to-one to build initial skills (Anderson et al., 1987; Lovaas, 1987; Ro- manczyk, Matey, & Lockshin, 1994), most programs actively build the requisite skills for small and large group participation. Individual instruction makes sense when the student has limited attention, responds idio- syncratically, requires physical guidance most of the time, lacks basic group readiness skills, and when the child is first introduced to teaching situations. Although the best outcomes have been reported by programs us- ing intensive one-to-one training for at least 2 years (Anderson et al., 1987; Lovaas, 1987), there have been no direct comparisons of the benefits of group versus individual instruction.

The potential benefits of group instruction are fun- damentally clear and are unlikely to produce much dis- agreement among professionals: (1) preparing the child for kindergarten and elementary classrooms, (2) pro- viding potential for incidental or observational learn- ing, and (3) providing an opportunity for social and language interactions with other children. What often seems to be at issue are when to introduce group in- struction and whether there are prerequisite skills. Again, we recommend that this become an issue of individualization and reasonable balance rather than rigid practice. It is also possible to blend methods by providing one-to-one within a group context (Kamps et al., 1991). In this format, one student receives instruc- tion while the same teacher supervises other students who are working independently (typically on a "back- ground task"). This method allows the teacher to move back and forth between individual and group instruc- tion and gives the child an opportunity to observe the behavior of other children. In our opinion, flexible

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models that allow fluid change from one context to another and movement between individual and group instruction are most likely to be successful.

Another factor that should be considered in choosing a context for learning concerns the number of instruc- tional opportunities. Children with autism appear to learn most readily through repetition or practice on a small set of targeted skills for learning. The number of instructional opportunities are influenced by many fac- tors including the total number of hours of intervention per day and the length of the intervention period in months or years. In addition, the size of the instruc- tional group may exert significant influence on the number of opportunities. Typically, as a child moves from individual to small group to large group, the num- ber of opportunities decreases. This is sometimes rea- sonable and appropriate, particularly when the goals are concerned with the acquisition of many kindergar- ten readiness skills (e.g., following instructions given to the group). Although each situation must be evaluated individually, it is necessary to strike a balance between the level of individual and group instruction that each child receives, continually evaluating and prioritizing the goals to be achieved.

In summary, the continuum based models often em- phasize one-to-one instruction to build an initial reper- toire of skills. Every effort is made to move the child along the continuum from one-to-one to small group to large group instruction.

Utilization of Multiple Instructional Techniques Myth: ABA exclusively uses teacher led, discrete tri-

als methods. Many parents and professionals equate ABA with an instructional technique called discrete trials. In discrete trials training (Anderson, Taras, & O'Malley Cannon, 1996; Koegel, Russo, & Rincover, 1977; Lovaas, 1981; Luyben, 1998), the instructor pro- vides a concise instruction, question, or activity when the child is most attending. If the child answers cor- rectly, the teacher praises enthusiastically and may re- ward the occurrence of the behavior with other signs of approval (a toy, pat on the back, food). If the child fails to respond or responds incorrectly, the instructor deliv- ers feedback and provides a prompt to ensure that the correct or desired response occurs. The form and level of the prompt (e.g., physical, gesture, verbal, partial physical) is determined individually but should be im- mediately successful and easily faded. Often, the trial is quickly repeated, giving the child an opportunity to practice what has just been shown. Most of us have learned something at one time or another using this method and it is unlikely by itself to be very controver- sial.

However, discrete trials methods also have become closely associated with other aspects of the instructional context. Initial instructional sessions can be very diffi-

cult for the learner with autism and as soon as the in- structor begins to set limits (e.g., insisting that the child remain seated), many children resist. To limit the child's mobility and to allow more effective prompting, the instructor and child often sit facing each other in chairs, with the child's legs resting between the instruc- tor's. The instructor then presents the lesson in the dis- crete trials format described above. A well trained in- structor will use a variety of techniques to assist and help the child feel comfortable with the situation (e.g., short sessions, introduction of familiar activities, physi- cal and verbal assistance, music or preferred activities interspersed with less preferred tasks, teaching an ap- propriate escape response). Nevertheless, even with the best laid plans, some children with autism will resist the intervention.

On the positive side, this form of instruction often results in rapid learning for many children. On the negative side, critics argue that the selection of lessons is too teacher directed and that it minimizes individual choice. However, the goal of the behavior analyst is to increase alternative responses so that the child acquires more freedom of choice (Alberto & Troutman, 1999). Children who lack functional communication skills and repeatedly fail to express their needs and wants are unlikely to make friends.

The discrete trials method had been contrasted with another behavioral approach called incidental teaching. This approach has been described and demonstrated to be effective for many children (McGee, Krantz, Mason, & McClannahan, 1983). In this method, the instructor assesses the child's ongoing interests, follows the child's lead, restricts access to high interest items, and con- structs a lesson within the natural context, with a pre- sumably more motivated child. This model produces rapid learning if the child frequently exhibits interests in objects and activities. On the other hand, if the child does not spontaneously show interest in many things, it is difficult to find enough instructional opportunities. Furthermore, ultimately it is desirable for a child to learn even in situations or circumstances that are not inherently interesting.

In our opinion, these techniques are both very im- portant and are not' necessarily incompatible. At any given point in time, each method may have benefits and limitations. It can be argued that a discrete trial is a naturally embedded part of an incidental teaching op- portunity (getting the child's attention, providing clear instruction, offering praise and support). For this rea- son, we prefer to use the phrase direct teaching rather than discrete trials to label the highly teacher directed situation described above. In a direct teaching situation, most instructors use a variety of techniques to naturally motivate children (e.g., incorporating child choice, re- inforcing attempts). In our opinion it is important to think of discrete trials and incidental teaching as end points along a continuum of teaching contexts and tech-

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170 Anderson and Romanczyk

niques (Table 1). In between the two ends is a gradient of situations that blend teacher directed and child ini- tiated opportunities for learning (we have identified one point as activities embedded). Each point along this continuum has advantages and disadvantages and each may be important for individuals at any given time in their development. Even within a single session, the best instructors will blend direct teaching and incidental teaching techniques. The decision to teach in a given context is again based on many individual variables in- cluding (but not limited to) the child's attention, indi- vidual distractibility, spontaneous interest in toys and materials, the lesson being taught, and most impor- tantly, the child's progress. It should not be a polarized decision but an individualized decision based on indi- vidual needs and objectively measured outcomes.

In summary, it is our opinion that continuum based models use many different instructional techniques to achieve the desired results moving up and down the continuum of teaching techniques (Table 1), matching the approach to the child's level and most effective style of learning.

Opportunities for Social Integration Myth: ABA cannot be applied in socially integrated

school settings. Some behavioral researchers have made compelling arguments for the benefits of teaching children with developmental disabilities in integrated settings (Jenkins, Odom, & Speltz, 1989). The underly- ing assumption is reasonable, that is, young children with disabilities will improve by observing the social and language models of their typically developing peers. In fact, many behavioral programs have reported the use of a social integration model (Anderson et al., 1994; McGee, Daly, & Jacobs, 1994; Strain & Cordisco, 1994). Although most behavior analysts recognize the importance of social integration for many children, one can find considerable variability as to when the integra- tion should occur.

A few programs have hypothesized that for some children, a period of individual and segregated small group instruction helps in preparing the children for later inclusionary experiences (Anderson et aI., 1994; Handleman & Harris, 1994). These programs typically provide a gradual progression from individual (home or

center based) to small group (often segregated) to large group instruction (integrated). Many of these programs also report success in transitioning children to kinder- garten placements within regular schools.

When inclusion is the choice of parents and profes- sionals, it is important to remember that simple expo- sure to typically developing children may not be suffi- cient to produce measurable gains. Furthermore, close proximity does not preclude that children might dem- onstrate highly idiosyncratic patterns of participation (Kohler, Strain, & Shearer, 1996). There must be an individual focus for the evaluation of inclusion that in- cludes parents and teachers. As part of the decision making progress, these individuals must make decisions about the sequence of the curriculum and the balance between individualization and inclusion.

The behavioral strategies and techniques that are ap- plied in segregated settings also can be applied in inte- grated settings. Anderson et al. (1994) described an in- tegrated setting in which teachers organized learning centers and the children were free to move among areas as they chose. Specific educational objectives for each child were embedded into these play activities, often using task analysis so that teaching occurred at the child's current level and gradually increased in com- plexity. While these activities were occurring, students were removed individually or as part of a small group for brief periods of instruction on other educational objectives that were less easy to embed or that required significant repetition for learning. Methods for ongoing assessment and data driven decision making were di- rectly built into the system. The program employed be- havioral practices common to most quality programs: (1) clearly defined skills to be learned; (2) baseline and ongoing assessment; (3) systematic introduction of be- havior intervention methods; and (4) a broad context for learning that included direct teaching, embedded trials, and incidental teaching,

In summary, the continuum-based models typically employ a strategy of a continuum of services from in- tense individualized services in a specialized setting (or home) to more typical classrooms with required sup- port. This allows the rapid acquisition of skills and a systematic and planned approach to integration.

Table 1 A Brief Description of Three Different Points Along a Continuum of Contexts For Learning

Direct teaching Activities embedded Incidental teaching

• Usually one-to-one • Highly structured • Teacher directed • Many instructional opportunities • Skills acquired quickly • Distractions minimized • Easier to manage behavior problems • Generalization may be restricted

• Usually small group • Shared teacher/child control • Some natural distractions • Typically few instructional opportunities • Moderate level of structure • Challenging to find reinforcing activities • Generalization may be enhanced

• Small and large group • Most natural • Child directed • Natural distractions • Challenging to find reinforcing activities • Typically fewer instructional

opportunities • Generalization may be enhanced

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Individualized Instructional Curriculum Myth: ABA does not develop functional skills. A

common characteristic of children with autism is the failure to generalize skills across conditions and re- sponses dissimilar from the original training. For ex- ample, children who learn to identify several common body parts (nose, ear, eye) when applied to themselves, may fail to generalize when asked to identify the same parts on a doll. Similarly, a child who learns to imitate simple motor movements (e.g., pat stomach, touch hand to head) could fail to learn the more general rule (i.e., "Do as I do"). Many of the skills targeted for initial instruction (e.g., motor imitation, matching com- mon objects, following instructions) are considered functional in that they provide the foundation for teaching many other things (communication, academic, self-care) .

During initial training situations, some teachers main- tain unusually tight control over the instructions pro- vided, the materials presented, the child's positioning, and other setting conditions. This level of control is often needed to help children attend to the task, mini- mize distractions, and break the activity into a series of small steps for learning. Teaching in this manner may lead to rapid acquisition of skills but sometimes mini- mizes generalization. However, as children become in- creasingly more responsive to instruction, it is possible to simultaneously teach under more natural conditions or to initiate instruction within an embedded or inci- dental teaching format. We again refer to the impor- tance of using the full context continuum for learning (Table 1).

For many children, instructional targets are quickly learned and generalized to settings, materials, and con- ditions different from the learning context. For other children, very little generalization occurs and most ev- erything the child learns will have to be taught directly. The failure to generalize (or develop rule governed be- havior) may be a result of many variables: (1) poorly selected goals for learning (learned behaviors did not meet a natural community of reinforcement), (2) fail- ure of the instructor to actively program generalization, and (3) limitations in our current technology to teach and promote generalization for the most challenging children. It is fair to say that most children will benefit, to a greater or less extent, from intensive behavioral interventions. However, the rates of learning and the range of outcomes for children may be as broad as the disorder itself (Weiss, 1999). Some children fail to dis- play newly acquired skills except under highly teacher directed conditions (someone gives them a verbal in- struction, models the desired behavior, or gestures to- ward materials). Clearly, practitioners of ABA cannot be satisfied with producing simple behavior change in highly controlled conditions without fully considering how the skill will be used in more natural situations.

However, there is little evidence to support an alterna- tive hypothesis that learning in all cases is likely to be more successful when provided in the natural context. Fortunately, there is an emerging set of techniques (train diversity, incorporate functional mediators, in- clude natural communities) that when applied system- atically often produce the desired results (Stokes & Os- nes, 1988). It is important to provide an individual child focus for the use and evaluation of these instructional techniques.

In summary, the continuum based models consider many variables when determining skills to be taught and the context for learning to occur. As we stated earlier, a curriculum for children with autism cannot be seen as a linear sequence of skills to be learned in order. For the very young child, many skill targets are chosen because they are believed to be functional in develop- ing a foundation for teaching other skills. In the older child, skills are functional because they enable the child to live a more independent lifestyle. Once a target skill has been selected, other factors may influence the con- text in which teaching will occur (e.g., child's attention, need for one-to-one). Again, we argue that the indi- vidual child focus be maintained and the full context continuum for learning be available.

Development of a Behavioral Support Plan Myth: ABA uses aversive techniques to manage be-

havior problems. Children with autism often display challenging behaviors that interfere with learning. It is our sense that all continuum based models emphasize methods to teach new skills rather than a singular focus on managing challenging behavior. Initially, problem behaviors are handled through a rich schedule of rein- forcement that builds adaptive skills. For example, in these programs, much of early learning is helping the child to acquire and generalize the ability to follow simple instructions and to use appropriate behavior to gain attention or escape from undesired requests. Many behavior problems improve as the child's ability to communicate and respond to simple instructions im- proves (Luiselli, 1990). As it was indicated earlier, the first job of the behavior analyst is to make the sessions fun for the child (e.g., short, familiar, and motivating). Positive results can be enhanced by teaching the child an appropriate communication skill that replaces the problem behaviors. The direct teaching approach de- scribed above often is the context for teaching the child the earliest skills to be learned. Gradually, expectations are increased and emerging skills are reinforced during natural school, home, and community contexts.

Some behavior problems continue to persist during or outside the direct teaching context regardless of well intentioned efforts. At this point, well trained behavior analysts develop an intervention plan after obtaining information through a detailed functional assessment (O'Neill et al., 1997). In this approach, the behavior

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analyst conducts careful assessments to identify events that reliably predict and maintain the behavior. Subse- quently, a behavior support plan is developed that is linked to the assessment and modifies antecedent events, teaches replacement behaviors, and changes maintaining consequences.

In summary, the continuum based models primarily use a skills oriented approach to improving the child's behavior. When serious behavior problems do not im- prove with skill reinforcement and redirection proce- dures, a careful analysis is conducted and a behavior support plan is developed.

Conclusions At this time, controlled research indicates that com-

prehensive, well conducted use of ABA offers the most hope for children with autism and their families. In this article, we first provided the reader with a description of programmatic and methodologic common elements of ABA. It is our opinion that little disagreement exists within the behavioral community regarding the general elements that should be present in a quality program. However, as is common with any approach, often there are differences in the specific intervention techniques that are chosen, the proportion of one technique versus another, and the sequencing and timing of their use. The diversity of these techniques has created confusion regarding the combination of behavioral techniques that is most likely to be effective. It is our opinion that ABA includes a large number of conceptually consis- tent techniques that can, and should, be used in various combinations across many different contexts.

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Article received: April 29, 1999 Final acceptance: August 2, 1999 Editor in charge: Fredda Brown

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