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TheEthicsofActuallyHelpingPeople-TargetingSkillAcquisitionGoalsThatPromoteMeaningfulOutcomesforIndividualswithAutismSpectrumDisorder.pdf
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The Ethics of Actually Helping People: Targeting Skill Acquisition Goals That
Promote Meaningful Outcomes for Individuals with Autism Spectrum
Disorder
Article in Behavior Analysis in Practice · December 2022
DOI: 10.1007/s40617-022-00757-x
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Behavior Analysis in Practice https://doi.org/10.1007/s40617-022-00757-x
DISCUSSION AND REVIEW PAPER
The Ethics of Actually Helping People: Targeting Skill Acquisition Goals That Promote Meaningful Outcomes for Individuals with Autism Spectrum Disorder
Shanna Bahry1,2 · Peter F. Gerhardt1,3 · Mary Jane Weiss1 · Justin B. Leaf1,4 · Robert F. Putnam1,5 · Andy Bondy6
Accepted: 28 October 2022 © Association for Behavior Analysis International 2022
Abstract As a field that predominately supports individuals with autism spectrum disorder (ASD), we have an ethical duty as behavior analysts to ensure that the goals we write and interventions we prescribe promote best outcomes across the lifespan. This is critical, given that as it stands now, outcomes in adulthood for individuals with ASD are poor in every area assessed. The Ethics Code for Behavior Analysts can be interpreted to provide support for teaching the right goals, the right way, with respect to inherent rights of those we serve, in order to help affect positive changes in these outcomes. The present article highlights ethical themes that are relevant in order to affect these changes that are supported by the Code, as well as actionable steps to take next. The aim is to provide a resource for practitioners to use in clinical practice and in making ethical decisions that will help to improve outcomes for individuals with autism in adulthood. In addition, recommendations are made about integrating these values and approaches in terms of training, supervision, advocacy, and research.
Keywords Autism spectrum disorder (ASD) · Outcomes · Applied behavior analysis · Ethics · Adolescence · Adulthood
In the chapter, “The Ethics of Helping People,” B. F. Skinner (1975/1996) stated, “One has most effectively helped others when one can stop helping them altogether" (p. 63). As a logical extension, to most effectively help individuals with autism spectrum disorder (ASD),1 we must ensure that they are adequately prepared for as independent a life as possible across their lifespan. This is important given that, as it stands now, outcomes in adulthood for individuals with ASD are generally poor in every area assessed, including postsecond- ary education, employment, independent living, social and community participation, access to services, and health and safety (Lai et al., 2019; Orsmond et al., 2013; Roux et al., 2015; Schroeder et al., 2014; Shattuck et al., 2012). These
outcomes are worse than typically developing individuals as well as those with other disability labels (Roux et al., 2015), and have shown little improvement over the years (Howlin, 2021; Newman et al., 2010; Shattuck et al., 2020). Recent research suggested that about half of adults on the autism spectrum had poor outcomes based on a variety of measures, and less than a quarter had well-integrated lives character- ized by quality outcomes (Mason et al., 2021; Steinhausen et al., 2016). In addition, the quality of life (QoL) of adults with autism has been reported as being generally lower than that of typically developing adults when tools designed for the general population are used (Ayres et al., 2018).
As of late 2020, 73.16% of Behavior Analyst Certification Board (BACB) certificants (i.e., BCBA-D, BCBA, BCaBA, and RBT) identified their primary area of professional emphasis as ASD (BACB, n.d.). Given that about three quar- ters of the field of applied behavior analysis (ABA) primarily works with individuals with ASD, it seems reasonable to
* Shanna Bahry [email protected]
1 Endicott College, Beverly, MA, USA 2 Meaningful HOPE, East Providence, RI, USA 3 The EPIC School, Paramus, NJ, USA 4 Autism Partnership Foundation, Seal Beach, CA, USA 5 May Institute, Randolph, MA, USA 6 Pyramid Educational Consultants, New Castle, DE, USA
1 A note about terminology: throughout this article, the terms “autism,” “on the autism spectrum,” “ASD,” “person with autism,” and “autistic person” are used interchangeably. Although the authors recognize that among the clinical, medical, and neurodiverse commu- nities there are preferences and conventions in terminology use, the selection of terminology in this article is based on grammar and sty- listic needs and does not reflect a particular terminological intent.
Behavior Analysis in Practice
interpret our ethical guidelines in terms of directing best practice within this specific population. As behavior ana- lysts, we are arguably ethically bound to ensure that the goals we write and the interventions we prescribe promote quality outcomes across the lifespan for those that we serve. As such, the purpose of the present article is to: (1) draw attention to the problem of poor adult ASD outcomes and the attainable, yet insufficiently employed solution of effec- tively teaching the right skills the right way; (2) describe potential unintended contributions to this problem; (3) pro- pose how behavior analytic practice can contribute to the solution, if guided by two major ethical themes supported by expanded applications of the most recent Ethics Code (BACB, 2020); and (4) present the field of behavior analytic intervention with a call to action targeted at ensuring ade- quate resources are available for advocacy, dissemination, networking, and expertise of current and future practitioners who choose to work with individuals with autism. Through- out this article, references to specific ethical standards and core principles from the Ethics Code for Behavior Analysts (BACB, 2020) are made in parentheses following statements or ideas to which the authors consider them applicable. In these instances, it is suggested that the reader (1) refer to Table 1, which provides an overview of each standard as written in the Code (BACB, 2020) as well as additional interpretations that are suggested; and (2) refer to Table 2, which provides the core principles exactly as written in the Code (BACB, 2020) so that they may be quickly accessed and read critically, allowing for suggested interpretations to be considered.
We, as the authors, recognize that ASD represents a com- plex “spectrum” (American Psychiatric Association, 2013) and that outcomes for individuals on one end of the spec- trum will look different than for individuals on the other end, with high degrees of variability in between (Georgiades & Kasari, 2018). In addition, each individual with a diagno- sis of autism is unique and likely does not fit neatly into a given category. Regardless, concerns regarding outcomes should be central to making programmatic and intervention decisions. This article offers general recommendations that should be read with attention to how they can be applied to any client, regardless of age, developmental level, or cur- rent skills repertoire. Although our recommendations, we believe, apply to all individuals with autism, specific atten- tion should be given to how practitioners can best affect
adult outcomes by effectively planning for this transition by teaching the right skills, the right way, as early as possible.2
The Problem of Poor Adult Outcomes and Adaptive Behavior Skills as the Solution
Children with autism become adults with autism. Simply in terms of numbers, we are adults for far longer than we are children. According to the Centers for Disease Control and Prevention (CDC; Xu et al., 2020), the average life expectancy in the United States is 78.7 years. Considering adolescence as beginning at age 12 (Food & Drug Admin- istration [FDA], 2014; Hardin et al., 2017), and presuming a person were to live to the average life expectancy in the United States, this would mean that adolescence and adult- hood account for about 86% of our lives, whereas child- hood only accounts for about 14%. Despite this fact, there is an alarming disparity in allocation of resources, avail- ability of supports, diversity of research, and a deficit in the field of behavior analysis for serving this age group and for preparing those transitioning to this age group (Ander- son et al., 2018; Baker-Ericzén et al., 2018; Gerhardt & Lainer, 2011; Shattuck et al., 2020). In 2011, Gerhardt and Lainer referred to “a looming crisis of unprecedented magnitude for adults with autism, their families, and the ill-prepared and underfunded adult service system charged with meeting their needs” (p. 37); a decade later, this crisis has arrived and is in full swing.
Individuals with intellectual and developmental disabilities (IDD), including autism, often require lifelong support and, in many cases, 24-hour supervision (President’s Committee for People with Intellectual Disabilities [PCPID], 2017; Roux et al., 2015). Yet, the unfortunate reality is that the transi- tion from childhood to adulthood comes with a huge drop- off in funding and services for individuals with disabilities (Gerhardt & Lainer, 2011; Laxman et al., 2019; Marsack- Topolewski & Weisz, 2020; Roux et al., 2015; Shattuck et al., 2020). This drop-off exists in both the education and insur- ance-funded worlds, and is so profound that it is often referred to as “falling off a service cliff” (Roux et al., 2015). Although insurance-funded coverage is presently mandated across the United States, many states have limitations in coverage based on age, dollar amount, or hourly service caps for these neces- sary services, resulting in inequitable access depending on where you live (Autism Speaks, n.d.b). Likewise, although special education and transition services are mandated by fed- eral law ([Individuals with Disabilities Education Act] IDEA, 2004), after graduating from high school there is no clear, national mandate that requires support services in adulthood. For the most part, families are left to fend for themselves and advocate for these supports, which often do not readily exist (Roux et al., 2015; Shattuck et al., 2020).
2 The authors also note that, although this article is focused on ASD, the ideas discussed are applicable to a wide range of individ- uals, especially those with similar disability labels, such as various intellectual and developmental disabilities. Also, as is the case with all human behavior, the individual and their unique presentation of behavior within their given environment is more important than the specific disability label they may carry.
Behavior Analysis in Practice
Ta bl
e 1
P ro
po se
d ad
di tio
na l i
nt er
pr et
at io
ns o
f s ta
nd ar
ds w
ith in
th e
et hi
cs c
od e
fo r b
eh av
io r a
na ly
sts
BA C
B E
th ic
s C od
e fo
r B eh
av io
r A na
ly sts
(2 02
0) S
ta nd
ar d
A dd
iti on
al In
te rp
re ta
tio ns
Se ct
io n
1: R
es po
ns ib
ili ty
a s a
P ro
fe ss
io na
l 1.
05 Pr
ac tic
in g
w ith
in S
co pe
o f C
om pe
te nc
e B
eh av
io r a
na ly
sts p
ra ct
ic e
on ly
w ith
in th
ei r i
de nt
ifi ed
sc op
e of
c om
pe te
nc e.
T he
y en
ga ge
in p
ro fe
ss io
na l a
ct iv
iti es
in n
ew
ar ea
s ( e.
g. , p
op ul
at io
ns , p
ro ce
du re
s) o
nl y
af te
r a cc
es si
ng a
nd
do cu
m en
tin g
ap pr
op ria
te st
ud y,
tr ai
ni ng
, s up
er vi
se d
ex pe
rie nc
e,
co ns
ul ta
tio n,
a nd
/o r c
o- tre
at m
en t f
ro m
p ro
fe ss
io na
ls c
om pe
te nt
in
th e
ne w
a re
a. O
th er
w is
e, th
ey re
fe r o
r t ra
ns iti
on se
rv ic
es to
a n
ap pr
op ria
te p
ro fe
ss io
na l.
• B
eh av
io r a
na ly
sts ’ c
om pe
te nc
e m
ay in
cl ud
e sp
ec ifi
c ag
e gr
ou ps
w
ith in
p op
ul at
io ns
th ey
se rv
e, in
cl ud
in g
as se
ss m
en ts
u se
d, g
oa ls
ta
rg et
ed , a
nd in
te rv
en tio
ns u
se d
w ith
in th
es e
gr ou
ps .
• In
a dd
iti on
, e th
ic al
b eh
av io
r r eq
ui re
s b ot
h cl
in ic
al ju
dg em
en t a
nd
th e
w or
ld vi
ew o
f a ra
di ca
l b eh
av io
r a na
ly st,
w hi
ch in
cl ud
e co
re
co m
pe te
nc ie
s s uc
h as
th e
ab ili
ty to
m ak
e in
th e
m om
en t d
ec is
io ns
ba
se d
on th
e be
ha vi
or o
f o ur
c lie
nt s a
nd c
ha ng
es in
th ei
r e nv
iro n-
m en
t, to
th in
k ou
ts id
e of
th e
bo x,
a nd
th e
ab ili
ty to
tr ul
y in
di vi
du -
al iz
e tre
at m
en t.
(s am
e fo
r 3 .0
3 an
d 4.
02 )
Se ct
io n
2: R
es po
ns ib
ili ty
in P
ra ct
ic e
2. 01
Pr ov
id in
g Eff
ec tiv
e Tr
ea tm
en t
Be ha
vi or
a na
ly st
s p rio
rit iz
e cl
ie nt
s’ ri
gh ts
a nd
n ee
ds in
se rv
ic e
de liv
er y.
T he
y pr
ov id
e se
rv ic
es th
at a
re c
on ce
pt ua
lly c
on si
st- en
t w ith
b eh
av io
ra l p
rin ci
pl es
, b as
ed o
n sc
ie nt
ifi c
ev id
en ce
, an
d de
si gn
ed to
m ax
im iz
e de
si re
d ou
tc om
es fo
r a nd
p ro
te ct
a ll
cl ie
nt s,
st ak
eh ol
de rs
, s up
er vi
se es
, t ra
in ee
s, an
d re
se ar
ch p
ar tic
i- pa
nt s f
ro m
h ar
m . B
eh av
io r a
na ly
sts im
pl em
en t n
on be
ha vi
or al
se
rv ic
es w
ith c
lie nt
s o nl
y if
th ey
h av
e th
e re
qu ire
d ed
uc at
io n,
fo
rm al
tr ai
ni ng
, a nd
p ro
fe ss
io na
l c re
de nt
ia ls
to d
el iv
er su
ch
se rv
ic es
.
• B
eh av
io r a
na ly
sts sh
ou ld
p rio
rit iz
e cl
ie nt
s’ ri
gh ts
to b
eh av
io ra
l pr
og ra
m m
in g
th at
e m
ph as
iz es
ta rg
et in
g an
d pr
io rit
iz in
g fu
nc tio
na l
sk ill
s a nd
p er
so na
l w el
fa re
. •
B eh
av io
r a na
ly sts
sh ou
ld p
ro m
ot e
ou tc
om es
th at
a re
so ci
al ly
v al
id
ac ro
ss th
e lif
es pa
n. •
In c
on si
de rin
g th
e lo
ng -te
rm o
ut co
m es
o f t
re at
m en
t t ha
t i s
m ea
ni ng
fu l,
be ha
vi or
a na
ly sts
sh ou
ld p
ro m
ot e
ou tc
om es
th at
a re
ge
ne ra
liz ed
o ve
r t im
e an
d ac
ro ss
v ar
io us
e nv
iro nm
en ts
.
2. 09
In vo
lv in
g C
lie nt
s a nd
S ta
ke ho
ld er
s B
eh av
io r a
na ly
sts m
ak e
ap pr
op ria
te e
ffo rts
to in
vo lv
e cl
ie nt
s an
d re
le va
nt st
ak eh
ol de
rs th
ro ug
ho ut
th e
se rv
ic e
re la
tio ns
hi p,
in
cl ud
in g
se le
ct in
g go
al s,
se le
ct in
g an
d de
si gn
in g
as se
ss m
en ts
an
d be
ha vi
or -c
ha ng
e in
te rv
en tio
ns , a
nd c
on du
ct in
g co
nt in
ua l
pr og
re ss
m on
ito rin
g.
• B
eh av
io r a
na ly
sts sh
ou ld
e ns
ur e
th at
sk ill
a cq
ui si
tio n
ta rg
et s a
re
se le
ct ed
w ith
n ot
fo r c
lie nt
s a nd
st ak
eh ol
de rs
; t he
se sk
ill s s
ho ul
d be
v al
ua bl
e to
c ur
re nt
a nd
fu tu
re e
nv iro
nm en
ts a
nd p
ro m
ot e
lo ng
- te
rm w
el l-b
ei ng
a nd
h ap
pi ne
ss .
• B
eh av
io r a
na ly
sts sh
ou ld
c on
tin ua
lly se
ek v
al id
at io
n fro
m c
lie nt
s an
d st
ak eh
ol de
rs o
n th
e sk
ill s t
ar ge
te d,
th e
pr oc
ed ur
es u
se d,
a nd
th
e ou
tc om
es o
f t re
at m
en t.
2. 13
Se le
ct in
g, D
es ig
ni ng
, a nd
Im pl
em en
tin g
A ss
es sm
en ts
B ef
or e
se le
ct in
g or
d es
ig ni
ng b
eh av
io r-c
ha ng
e in
te rv
en tio
ns b
eh av
- io
r a na
ly sts
se le
ct a
nd d
es ig
n as
se ss
m en
ts th
at a
re c
on ce
pt ua
lly
co ns
ist en
t w ith
b eh
av io
ra l p
rin ci
pl es
; t ha
t a re
b as
ed o
n sc
ie nt
ifi c
ev id
en ce
; a nd
th at
b es
t m ee
t t he
d iv
er se
n ee
ds , c
on te
xt , a
nd
re so
ur ce
s o f t
he c
lie nt
a nd
st ak
eh ol
de rs
. T he
y se
le ct
, d es
ig n,
a nd
im
pl em
en t a
ss es
sm en
ts w
ith a
fo cu
s o n
m ax
im iz
in g
be ne
fit s a
nd
m in
im iz
in g
ris k
of h
ar m
to th
e cl
ie nt
a nd
st ak
eh ol
de rs
. T he
y su
m m
ar iz
e th
e pr
oc ed
ur es
a nd
re su
lts in
w rit
in g.
• B
eh av
io r a
na ly
sts sh
ou ld
ta ke
in to
a cc
ou nt
th e
cl ie
nt ’s
a ge
, d ev
el -
op m
en ta
l l ev
el , a
nd fu
nc tio
na l/a
da pt
iv e
sk ill
s c ur
re nt
ly in
th ei
r re
pe rto
ire w
he n
ch oo
si ng
sk ill
-b as
ed a
ss es
sm en
ts .
• B
eh av
io r a
na ly
sts sh
ou ld
u til
iz e
sk ill
-b as
ed a
ss es
sm en
ts a
s a g
ui de
to
d ev
el op
h ig
hl y
in di
vi du
al iz
ed p
ro gr
am m
in g
bu t f
oc us
o n
al l
re le
va nt
fa ct
or s p
er ta
in in
g to
p ro
m ot
in g
be st
lo ng
-te rm
o ut
co m
es
fo r t
he c
lie nt
. •
B eh
av io
r a na
ly sts
sh ou
ld u
til iz
e cl
in ic
al ju
dg em
en t t
o m
ak e
de ci
- si
on s r
el at
ed to
d es
ig n
an d
im pl
em en
ta tio
n of
a ss
es sm
en ts
.
Behavior Analysis in Practice
Ta bl
e 1
(c on
tin ue
d)
BA C
B E
th ic
s C od
e fo
r B eh
av io
r A na
ly sts
(2 02
0) S
ta nd
ar d
A dd
iti on
al In
te rp
re ta
tio ns
2. 14
Se le
ct in
g, D
es ig
ni ng
, a nd
Im pl
em en
tin g
Be ha
vi or
-C ha
ng e
In te
rv en
tio ns
B eh
av io
r a na
ly sts
se le
ct , d
es ig
n, a
nd im
pl em
en t b
eh av
io r-c
ha ng
e in
te rv
en tio
ns th
at : (
1) a
re c
on ce
pt ua
lly c
on si
ste nt
w ith
b eh
av io
ra l
pr in
ci pl
es ; (
2) a
re b
as ed
o n
sc ie
nt ifi
c ev
id en
ce ; (
3) a
re b
as ed
o n
as se
ss m
en t r
es ul
ts ; (
4) p
rio rit
iz e
po si
tiv e
re in
fo rc
em en
t p ro
ce -
du re
s; a
nd (5
) b es
t m ee
t t he
d iv
er se
n ee
ds , c
on te
xt , a
nd re
so ur
ce s
of th
e cl
ie nt
a nd
st ak
eh ol
de rs
. B eh
av io
r a na
ly sts
a ls
o co
ns id
er
re le
va nt
fa ct
or s (
e. g.
, r is
ks , b
en efi
ts , a
nd si
de e
ffe ct
s; c
lie nt
a nd
st
ak eh
ol de
r p re
fe re
nc e;
im pl
em en
ta tio
n effi
ci en
cy ; c
os t e
ffe c-
tiv en
es s)
a nd
d es
ig n
an d
im pl
em en
t b eh
av io
r-c ha
ng e
in te
rv en
- tio
ns to
p ro
du ce
o ut
co m
es li
ke ly
to m
ai nt
ai n
un de
r n at
ur al
ist ic
co
nd iti
on s.
Th ey
su m
m ar
iz e
th e
be ha
vi or
-c ha
ng e
in te
rv en
tio n
pr oc
ed ur
es in
w rit
in g
(e .g
., a
be ha
vi or
p la
n) .
• B
eh av
io r a
na ly
sts a
re e
xp ec
te d
to id
en tif
y ev
id en
ce -b
as ed
in
te rv
en tio
ns in
su ch
c om
pl ex
a re
as o
f h um
an c
om pe
te nc
e as
in de
- pe
nd en
ce , s
af et
y, se
lf- m
an ag
em en
t, co
m m
un ic
at io
n, ti
m e
m an
ag e-
m en
t, se
lf- ca
re , e
m pl
oy m
en t,
et c.
, t he
a cq
ui si
tio n
of w
hi ch
m ay
b e
as so
ci at
ed w
ith m
or e
po si
tiv e
ov er
al l o
ut co
m es
in a
du lth
oo d.
• B
eh av
io r a
na ly
sts sh
ou ld
ta ke
in to
c on
si de
ra tio
n th
e ch
ro no
lo gi
- ca
l a ge
o f t
he c
lie nt
, h is
o r h
er p
re fe
re nc
es a
nd d
efi ci
ts , a
nd th
e de
m an
ds o
f c ur
re nt
a nd
fu tu
re e
nv iro
nm en
ts w
he n
ch oo
si ng
sk ill
- ac
qu is
iti on
ta rg
et s.
• B
eh av
io r a
na ly
sts sh
ou ld
n ot
c ho
os e
sk ill
-a cq
ui si
tio n
ta rg
et s b
as ed
on
th ei
r s eq
ue nt
ia l o
rd er
o r s
im pl
e pr
es en
ce w
ith in
a sk
ill -b
as ed
as
se ss
m en
t; ta
rg et
ed sk
ill s s
ho ul
d be
h ig
hl y
in di
vi du
al iz
ed to
w ha
t is
m os
t m ea
ni ng
fu l f
or th
at p
ar tic
ul ar
c lie
nt .
• D
es pi
te th
e fa
ct th
at m
or e
co m
pl ic
at ed
p ro
ce du
re s m
ay b
e re
qu ire
d to
ta rg
et c
om m
un ity
-b as
ed a
da pt
iv e
sk ill
s, th
e co
rr ec
t pr
oc ed
ur es
to ta
rg et
th e
m os
t m ea
ni ng
fu l g
oa ls
sh ou
ld a
lw ay
s b e
us ed
w he
n at
a ll
po ss
ib le
, i n
or de
r t o
be ne
fit th
e cl
ie nt
. T hi
s m os
t of
te n
m ea
ns u
si ng
re al
m at
er ia
ls a
nd p
ra ct
ic in
g in
th e
en vi
ro nm
en t
w he
re th
e sk
ill w
ill u
lti m
at el
y ta
ke p
la ce
. •
In o
rd er
to m
in im
iz e
th e
ch al
le ng
es to
b eh
av io
r c ha
ng e
pr og
ra m
s th
at a
re in
he re
nt in
le ss
c on
tri ve
d en
vi ro
nm en
ts su
ch a
s a c
li- en
t’s h
om e,
c om
m un
ity , o
r p la
ce o
f e m
pl oy
m en
t, th
e fo
llo w
in g
co ns
id er
at io
ns sh
ou ld
b e
m ad
e w
he n
de si
gn in
g sk
ill -a
cq ui
si tio
n in
te rv
en tio
ns : (
1) th
e co
nt ex
t i n
w hi
ch in
str uc
tio n
ta ke
s p la
ce ; (
2)
th e
in te
ns ity
o f i
ns tru
ct io
n ne
ce ss
ar y
fo r t
he sk
ill to
b e
ac qu
ire d;
(3
) t he
e ffi
ci en
cy o
f i ns
tru ct
io n,
su ch
th at
th e
le as
t a m
ou nt
o f
re sp
on se
e ffo
rt to
b e
eff ec
tiv e
is re
qu ire
d; a
nd (4
) t he
v al
ue o
f t he
sk
ill to
th e
in di
vi du
al .
• B
eh av
io r a
na ly
sts a
re e
xp ec
te d
to d
ev el
op b
eh av
io r c
ha ng
e go
al s
th at
a re
so ci
al ly
v al
id a
nd to
id en
tif y
po te
nt ia
lly e
ffe ct
iv e
in te
r- ve
nt io
n str
at eg
ie s t
ha t a
re e
vi de
nc e-
ba se
d an
d ac
ce pt
ab le
to th
e co
m m
un ity
a t l
ar ge
.
Behavior Analysis in Practice
Ta bl
e 1
(c on
tin ue
d)
BA C
B E
th ic
s C od
e fo
r B eh
av io
r A na
ly sts
(2 02
0) S
ta nd
ar d
A dd
iti on
al In
te rp
re ta
tio ns
2. 15
M in
im iz
in g
R isk
o f B
eh av
io r-
C ha
ng e
In te
rv en
tio ns
B eh
av io
r a na
ly sts
se le
ct , d
es ig
n, a
nd im
pl em
en t b
eh av
io r-c
ha ng
e in
te rv
en tio
ns (i
nc lu
di ng
th e
se le
ct io
n an
d us
e of
c on
se qu
en ce
s)
w ith
a fo
cu s o
n m
in im
iz in
g ris
k of
h ar
m to
th e
cl ie
nt a
nd
st ak
eh ol
de rs
. T he
y re
co m
m en
d an
d im
pl em
en t r
es tri
ct iv
e or
pu
ni sh
m en
t-b as
ed p
ro ce
du re
s o nl
y af
te r d
em on
str at
in g
th at
de
si re
d re
su lts
h av
e no
t b ee
n ob
ta in
ed u
si ng
le ss
in tru
si ve
m ea
ns ,
or w
he n
it is
d et
er m
in ed
b y
an e
xi sti
ng in
te rv
en tio
n te
am th
at
th e
ris k
of h
ar m
to th
e cl
ie nt
o ut
w ei
gh s t
he ri
sk a
ss oc
ia te
d w
ith th
e be
ha vi
or -c
ha ng
e in
te rv
en tio
n. W
he n
re co
m m
en di
ng
an d
im pl
em en
tin g
re str
ic tiv
e or
p un
is hm
en t-b
as ed
p ro
ce du
re s,
be ha
vi or
a na
ly sts
c om
pl y
w ith
a ny
re qu
ire d
re vi
ew p
ro ce
ss es
(e
.g .,
a hu
m an
ri gh
ts re
vi ew
c om
m itt
ee ).
B eh
av io
r a na
ly sts
m us
t co
nt in
ua lly
e va
lu at
e an
d do
cu m
en t t
he e
ffe ct
iv en
es s o
f r es
tri ct
iv e
or p
un is
hm en
t-b as
ed p
ro ce
du re
s a nd
m od
ify o
r d is
co nt
in ue
th e
be ha
vi or
-c ha
ng e
in te
rv en
tio n
in a
ti m
el y
m an
ne r i
f i t i
s i ne
ffe c-
tiv e.
• B
eh av
io r a
na ly
sts sh
ou ld
n ot
e th
at ri
sk s i
nc lu
de th
os e
ris ks
a ss
oc i-
at ed
w ith
p oo
r o ut
co m
es in
a du
lth oo
d re
la te
d to
c om
pl ex
a re
as o
f hu
m an
c om
pe te
nc e
su ch
a s i
nd ep
en de
nc e,
sa fe
ty , s
el f-
m an
ag e-
m en
t, co
m m
un ic
at io
n, ti
m e
m an
ag em
en t,
se lf-
ca re
, e m
pl oy
m en
t, et
c. ; t
he m
os t e
ss en
tia l a
nd m
ea ni
ng fu
l s ki
lls p
os si
bl e
sh ou
ld b
e ta
rg et
ed to
p os
iti ve
ly a
vo id
su ch
ri sk
s. •
B eh
av io
r a na
ly sts
sh ou
ld n
ot e
th at
in di
vi du
al s o
f d iv
er se
a bi
lit ie
s al
so h
av e
th e
rig ht
to th
e di
gn ity
o f r
is k;
si tu
at io
ns in
vo lv
in g
ap pr
op ria
te a
nd re
as on
ab le
ri sk
c an
, a nd
sh ou
ld , b
e in
co rp
or at
ed
in to
p ro
gr am
m in
g of
th os
e w
e se
rv e;
th is
d ig
ni ty
o f r
is k
sh ou
ld
al w
ay s b
e ba
la nc
ed w
ith e
du ca
tio n,
p re
pa ra
tio n
an d
ap pr
op ria
te
sa fe
ty p
re ca
ut io
ns .
2. 18
C on
tin ua
l E va
lu at
io n
of th
e Be
ha vi
or -C
ha ng
e In
te rv
en tio
n B
eh av
io r a
na ly
sts e
ng ag
e in
c on
tin ua
l m on
ito rin
g an
d ev
al ua
tio n
of b
eh av
io r-c
ha ng
e in
te rv
en tio
ns . I
f d at
a in
di ca
te th
at d
es ire
d ou
tc om
es a
re n
ot b
ei ng
re al
iz ed
, t he
y ac
tiv el
y as
se ss
th e
si tu
at io
n an
d ta
ke a
pp ro
pr ia
te c
or re
ct iv
e ac
tio n.
W he
n a
be ha
vi or
a na
ly st
is c
on ce
rn ed
th at
se rv
ic es
c on
cu rr
en tly
d el
iv er
ed b
y an
ot he
r p ro
- fe
ss io
na l a
re n
eg at
iv el
y im
pa ct
in g
th e
be ha
vi or
-c ha
ng e
in te
rv en
- tio
n, th
e be
ha vi
or a
na ly
st ta
ke s a
pp ro
pr ia
te st
ep s t
o re
vi ew
a nd
ad
dr es
s t he
is su
e w
ith th
e ot
he r p
ro fe
ss io
na l.
• B
eh av
io r a
na ly
sts sh
ou ld
p rio
rit iz
e lo
ng -te
rm o
ut co
m es
b y
m ak
in g
ne ce
ss ar
y ch
an ge
s t o
sk ill
a cq
ui si
tio n
pr og
ra m
m in
g if
su ffi
ci en
t pr
og re
ss is
n ot
b ei
ng m
ad e,
in o
rd er
fo r t
he c
lie nt
to m
or e
qu ic
kl y
m as
te r m
ea ni
ng fu
l s ki
lls th
at w
ill le
ad to
m or
e op
po rtu
ni tie
s i n
ad ul
th oo
d.
Behavior Analysis in Practice
Ta bl
e 1
(c on
tin ue
d)
BA C
B E
th ic
s C od
e fo
r B eh
av io
r A na
ly sts
(2 02
0) S
ta nd
ar d
A dd
iti on
al In
te rp
re ta
tio ns
Se ct
io n
3: R
es po
ns ib
ili ty
to C
lie nt
s a nd
S ta
ke ho
ld er
s
3. 01
R es
po ns
ib ili
ty to
C lie
nt s
Be ha
vi or
a na
ly st
s a ct
in th
e be
st in
te re
st of
c lie
nt s,
ta ki
ng a
pp ro
- pr
ia te
st ep
s t o
su pp
or t c
lie nt
s’ ri
gh ts
, m ax
im iz
e be
ne fit
s, an
d do
no
h ar
m . T
he y
ar e
al so
k no
w le
dg ea
bl e
ab ou
t a nd
c om
pl y
w ith
ap
pl ic
ab le
la w
s a nd
re gu
la tio
ns re
la te
d to
m an
da te
d re
po rti
ng
re qu
ire m
en ts
.
• C
lie nt
’s ri
gh ts
in cl
ud e
th os
e re
la te
d to
q ua
lit y
of li
fe , w
hi ch
b eh
av -
io r a
na ly
sts sh
ou ld
a ss
es s a
nd se
ek to
sy ste
m at
ic al
ly in
cr ea
se fo
r ea
ch in
di vi
du al
c lie
nt .
• B
eh av
io r a
na ly
sts sh
ou ld
b eg
in a
ll pr
og ra
m m
at ic
d ec
is io
ns w
ith
qu al
ity o
f l ife
in a
du lth
oo d
in m
in d
an d
se ek
to u
se o
ur sc
ie nc
e fo
r its
in te
nd ed
p ur
po se
o f i
m pr
ov in
g th
e liv
es o
f t ho
se w
e se
rv e.
• Pr
og ra
m m
in g
sh ou
ld a
lw ay
s b e
ai m
ed a
t w ay
s i n
w hi
ch c
lie nt
s ca
n sa
fe ly
a nd
e ffe
ct iv
el y
in cr
ea se
a cc
es s t
o th
os e
ite m
s, ac
tiv iti
es ,
pe op
le , o
r e nv
iro nm
en ts
im po
rta nt
to th
em ; t
hi s i
nc lu
de s t
he ri
gh t
to h
av e,
a nd
b e
tre at
ed w
ith , d
ig ni
ty b
y th
os e
ar ou
nd th
em a
nd
ev en
so ci
et y
at la
rg e.
T he
e th
ic al
b eh
av io
r a na
ly st
sh ou
ld a
lw ay
s sp
ea k
an d
be ha
ve in
w ay
s t ha
t u ph
ol d
th e
in na
te d
ig ni
ty o
f a ll
cl ie
nt s.
• C
on si
de ra
tio n
sh ou
ld b
e m
ad e
to a
pp lic
ab le
la w
s d es
ig ne
d to
pr
om ot
e an
d pr
ot ec
t t he
ri gh
ts o
f i nd
iv id
ua ls
w ith
d is
ab ili
tie s
is im
po rta
nt , s
uc h
as th
os e
th at
c al
l f or
th e
rig ht
s o f a
ll to
e nj
oy
in de
pe nd
en ce
, c ho
ic e
m ak
in g,
in cl
us io
n w
ith in
th e
co m
m un
ity ,
in te
gr at
io n
in to
a ll
as pe
ct s o
f s oc
ie ty
a t l
ar ge
in cl
ud in
g m
ak in
g co
nt rib
ut io
ns to
th at
so ci
et y,
a nd
a cc
es s t
o in
te rd
ep en
de nt
re la
tio n-
sh ip
s a nd
a li
fe e
nr ic
he d
w ith
le is
ur e
an d
so ci
al o
pp or
tu ni
tie s,
am on
gs t o
th er
ri gh
ts .
3. 03
A cc
ep tin
g C
lie nt
s B
eh av
io r a
na ly
sts o
nl y
ac ce
pt c
lie nt
s w ho
se re
qu es
te d
se rv
ic es
ar
e w
ith in
th ei
r i de
nt ifi
ed sc
op e
of c
om pe
te nc
e an
d av
ai la
bl e
re so
ur ce
s ( e.
g. , t
im e
an d
ca pa
ci ty
fo r c
as e
su pe
rv is
io n,
st affi
ng ).
W he
n be
ha vi
or a
na ly
sts a
re d
ire ct
ed to
a cc
ep t c
lie nt
s o ut
si de
o f
th ei
r i de
nt ifi
ed sc
op e
of c
om pe
te nc
e an
d av
ai la
bl e
re so
ur ce
s, th
ey
ta ke
a pp
ro pr
ia te
st ep
s t o
di sc
us s a
nd re
so lv
e th
e co
nc er
n w
ith
re le
va nt
p ar
tie s.
B eh
av io
r a na
ly sts
d oc
um en
t a ll
ac tio
ns ta
ke n
in
th is
c irc
um st
an ce
a nd
th e
ev en
tu al
o ut
co m
es .
• B
eh av
io r a
na ly
sts ’ c
om pe
te nc
e m
ay in
cl ud
e sp
ec ifi
c ag
e gr
ou ps
w
ith in
p op
ul at
io ns
th ey
se rv
e, in
cl ud
in g
as se
ss m
en ts
u se
d, g
oa ls
ta
rg et
ed , a
nd in
te rv
en tio
ns u
se d
w ith
in th
es e
gr ou
ps .
• In
a dd
iti on
, e th
ic al
b eh
av io
r r eq
ui re
s b ot
h cl
in ic
al ju
dg em
en t a
nd
th e
w or
ld vi
ew o
f a ra
di ca
l b eh
av io
r a na
ly st,
w hi
ch in
cl ud
e co
re
co m
pe te
nc ie
s s uc
h as
th e
ab ili
ty to
m ak
e in
th e
m om
en t d
ec is
io ns
ba
se d
on th
e be
ha vi
or o
f o ur
c lie
nt s a
nd c
ha ng
es in
th ei
r e nv
iro n-
m en
t, to
th in
k ou
ts id
e of
th e
bo x,
a nd
th e
ab ili
ty to
tr ul
y in
di vi
du -
al iz
e tre
at m
en t.
3. 12
A dv
oc at
in g
fo r
A pp
ro pr
ia te
S er
vi ce
s B
eh av
io r a
na ly
sts a
dv oc
at e
fo r a
nd e
du ca
te c
lie nt
s a nd
st ak
eh ol
d- er
s a bo
ut e
vi de
nc e-
ba se
d as
se ss
m en
t a nd
b eh
av io
r- c
ha ng
e in
te rv
en tio
n pr
oc ed
ur es
. T he
y al
so a
dv oc
at e
fo r t
he a
pp ro
pr ia
te
am ou
nt a
nd le
ve l o
f b eh
av io
ra l s
er vi
ce p
ro vi
si on
a nd
o ve
rs ig
ht
re qu
ire d
to m
ee t d
efi ne
d cl
ie nt
g oa
ls .
• In
a dv
oc at
in g
fo r c
lie nt
s, be
ha vi
or a
na ly
sts sh
ou ld
e ns
ur e
th at
th ey
ad
vo ca
te fo
r s er
vi ce
s t ha
t a re
so ci
al ly
v al
id , m
ea ni
ng fu
l, ap
pl ie
d in
na
tu re
, a nd
p ro
m ot
e qu
al ity
lo ng
-te rm
o ut
co m
es in
a du
lth oo
d. •
B eh
av io
r a na
ly sts
sh ou
ld a
ls o
ad vo
ca te
fo r s
er vi
ce d
el iv
er y
m od
- el
s t o
in cr
ea se
b ey
on d
ch ild
ho od
y ea
rs to
m ee
t t he
n ee
ds o
f c lie
nt s
w ho
re qu
ire se
rv ic
es a
cr os
s t he
li fe
sp an
, i nc
lu di
ng a
dv oc
at in
g fo
r im
pr ov
em en
ts in
th e
re cr
ui tm
en t,
re te
nt io
n, a
nd tr
ai ni
ng o
f s ta
ff ac
ro ss
a ll
se tti
ng s.
Behavior Analysis in Practice
Ta bl
e 1
(c on
tin ue
d)
BA C
B E
th ic
s C od
e fo
r B eh
av io
r A na
ly sts
(2 02
0) S
ta nd
ar d
A dd
iti on
al In
te rp
re ta
tio ns
Se ct
io n
4: R
es po
ns ib
ili ty
to S
up er
vi se
es a
nd T
ra in
ee s
4. 02
Su pe
rv iso
ry C
om pe
te nc
e B
eh av
io r a
na ly
sts su
pe rv
is e
an d
tra in
o th
er s o
nl y
w ith
in th
ei r i
de n-
tifi ed
sc op
e of
c om
pe te
nc e.
T he
y pr
ov id
e su
pe rv
is io
n on
ly a
fte r
ob ta
in in
g kn
ow le
dg e
an d
sk ill
s i n
eff ec
tiv e
su pe
rv is
or y
pr ac
tic es
, an
d th
ey c
on tin
ua lly
e va
lu at
e an
d im
pr ov
e th
ei r s
up er
vi so
ry
re pe
rto ire
s t hr
ou gh
p ro
fe ss
io na
l d ev
el op
m en
t.
• B
eh av
io r a
na ly
sts ’ c
om pe
te nc
e m
ay in
cl ud
e sp
ec ifi
c ag
e gr
ou ps
w
ith in
p op
ul at
io ns
th ey
se rv
e, in
cl ud
in g
as se
ss m
en ts
u se
d, g
oa ls
ta
rg et
ed , a
nd in
te rv
en tio
ns u
se d
w ith
in th
es e
gr ou
ps .
• In
a dd
iti on
, e th
ic al
b eh
av io
r r eq
ui re
s b ot
h cl
in ic
al ju
dg em
en t a
nd
th e
w or
ld vi
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Behavior Analysis in Practice
Table 2 Core Principles from The Ethics Code for Behavior Analysts (BACB, 2020, p. 4)
Four foundational principles, which all behavior analysts should strive to embody, serve as the framework for the ethics standards. Behavior analysts should use these principles to interpret and apply the standards in the Code. The four core principles are that behavior analysts should: benefit others; treat others with compassion, dignity, and respect; behave with integrity; and ensure their own competence
1 Benefit Others. Behavior analysts work to maximize benefits and do no harm by:
• Protecting the welfare and rights of clients above all others • Protecting the welfare and rights of other individuals with whom
they interact in a professional capacity • Focusing on the short- and long-term effects of their professional
activities • Actively identifying and addressing the potential negative impacts of
their own physical and mental health on their professional activities • Actively identifying potential and actual conflicts of interest and
working to resolve them in a manner that avoids or minimizes harm • Actively identifying and addressing factors (e.g., personal, financial,
institutional, political, religious, cultural) that might lead to conflicts of interest, misuse of their position, or negative impacts on their professional activities
• Effectively and respectfully collaborating with others in the best interest of those with whom they work and always placing clients’ interests first
2 Treat Others with Compassion, Dignity, and Respect. Behav- ior analysts behave toward others with compassion, dignity, and respect by:
• Treating others equitably, regardless of factors such as age, disabil- ity, ethnicity, gender expression/identity, immigration status, marital/ relationship status, national origin, race, religion, sexual orientation, socioeconomic status, or any other basis proscribed by law
• Respecting others’ privacy and confidentiality • Respecting and actively promoting clients’ self-determination to the
best of their abilities, particularly when providing services to vulner- able populations
• Acknowledging that personal choice in service delivery is important by providing clients and stakeholders with needed information to make informed choices about services
3 Behave with Integrity. Behavior analysts fulfill responsibilities to their scientific and professional communities, to society in general, and to the communities they serve by:
• Behaving in an honest and trustworthy manner • Not misrepresenting themselves, misrepresenting their work or oth-
ers’ work, or engaging in fraud • Following through on obligations • Holding themselves accountable for their work and the work of their
supervisees and trainees, and correcting errors in a timely manner • Being knowledgeable about and upholding BACB and other regula-
tory requirements • Actively working to create professional environments that uphold
the core principles and standards of the Code • Respectfully educating others about the ethics requirements of
behavior analysts and the mechanisms for addressing professional misconduct
4 Ensure their Competence. Behavior analysts ensure their compe- tence by:
• Remaining within the profession’s scope of practice • Remaining current and increasing their knowledge of best practices
and advances in ABA and participating in professional development activities
• Remaining knowledgeable and current about interventions (includ- ing pseudoscience) that may exist in their practice areas and pose a risk of harm to clients
• Being aware of, working within, and continually evaluating the boundaries of their competence
• Working to continually increase their knowledge and skills related to cultural responsiveness and service delivery to diverse groups
Behavior Analysis in Practice
Given the current state of funding and limited availability of adequate services and supports for adults with autism and other developmental disabilities (Autism Speaks, n.d.b; Vohra et al., 2014), it is of the utmost importance that practitioners maximize the time and resources available during childhood, while rich resources and funding sources are available (e.g., IDEA, 2004; Marsack-Topolewski & Weisz, 2020; Shattuck et al., 2020). In general, young adults on the spectrum are not provided the skills necessary to make a successful transition to life after high school (Eilenberg et al., 2019; Gerhardt & Lainer, 2011; Kuo et al., 2018; Shattuck et al., 2018), so tar- geting meaningful goals in preparation for adulthood is criti- cal if adult outcomes are to improve. Meaningful goals are individualized, inclusive of the learner’s unique needs and interests, and focused on building independence in both cur- rent and future environments (Ayres et al., 2011). A meaning- ful curriculum assesses an individual’s needs and prioritizes skill acquisition targets based on what is most important to their lives. Many meaningful skill areas include those related to adaptive behavior, which can be categorized as those skills that allow individuals to meet standards of personal independ- ence expected for their age or social group (Heward, 2005).
Adaptive skills have been shown to positively affect out- comes more so than factors such as cognitive level or autism symptom severity (Farley et al., 2009; Szatmari et al., 2003; Yeo & Teng, 2015), particularly when measures such as quality of life and social inclusion are reported (Bishop- Fitzpatrick et al., 2016; Esbensen et al., 2010; Kirby, 2016; Orsmond et al., 2013). Such research has led some to sug- gest that success in adulthood can be best thought of as the degree of independence one has, making adaptive behavior one way to clearly measure outcomes (Kanne et al., 2011). As Gerhardt et al. (2013) noted, “Adaptive behavior is so central to adult life that it would not be an understatement to say that adaptive behavior will get a person through times of no academic skills better than academic skills will get a per- son through times of no adaptive behavior” (p. 159). Becom- ing independent is important, as it often leads to increased access to privacy, choice, and dignity, as well as decreased financial, social, and emotional pressures being placed on others in their lives (Brown et al., 1976; Dell’Armo & Tassé, 2019; Lin, 2011; Marsack-Topolewski et al., 2021). Yet, for individuals on the autism spectrum, research has consist- ently documented that adaptive behavior deficits are present and substantial, regardless of intellectual level (e.g., Bellini et al., 2007; Szatmari et al., 2003; Tomanik et al., 2007), and that these deficits become more apparent with age (Klin et al., 2007). This suggests where practitioners should focus skill acquisition programming for individuals on the autism spectrum.
Although instruction in adaptive behavior would seem to present, at least partially, a solution to the problem of poor adult outcomes, the benefits of such have yet to be
realized (Clarke et al., 2021; Duncan et al., 2021; Farley et al., 2018; Hong et al., 2017; Howlin & Iliana, 2017; King et al., 2020; Lord et al., 2020). This means we are left in a situation where parents, practitioners, and funding sources only realize that, perhaps, they should have done things differently once it’s already too late (e.g., Ghanouni et al., 2021). Significant changes to current systems related to plan- ning and intervention are necessary in order to effectively meet the needs of adults on the spectrum and for preparing those transitioning to adulthood (Gerhardt & Lainer, 2011; Howlin, 2021; Shattuck et al., 2020).
Historical Context to How We Got Here: Unintentional Contributions to the Problem
Given the continued poor outcomes for the majority of adults on the spectrum, it is important to identify the various, well- meaning, and unintentionally problematic contributions to this situation. These contributions can be discussed in terms of the two primary funding streams by which behavior analytic services are resourced (i.e., federal/state-funded education services and medical insurance), each of which come with its own sets of benefits and barriers, as well as early research and focus within the field of behavior analysis. Each of these areas will be briefly reviewed in the following sections.
Special Education Funding Stream: Historical Inclusion Efforts The contributions of various legal mandates and relevant research that have benefited individuals with dis- abilities are worth noting. Prior to the deinstitutionalization efforts in the United States in the late 1970s, a common misconception was that individuals with disabilities would not benefit from public education (IDEA, 2004) Both civil rights (i.e., The Rehabilitation Act of 1973, 2010, Sect. 504) and educational entitlement (i.e., Education for All Handi- capped Children Act [EHA], Public Law 94–142, 1975; later reauthorized as the Individuals with Disabilities Education Act in 1990; IDEA, 2004) laws were enacted to enable all children with a disability label to access the same educa- tional rights as their typically developing peers, including access to a guaranteed free and appropriate public education (FAPE). During this time, a number of significant contribu- tions to the field were made by researchers and academics who focused on how to best serve this population in school settings (e.g., Brown et al., 1976; Gold, 1980; Haring & Brown, 1976). Continuous inclusion efforts led to educators conducting and publishing research on effective instructional programming for students with disabilities in inclusive set- tings (e.g., Haring, 1991; Haring & Romer, 1995; Meyer, 1994). These efforts often focused on inclusion in the physi- cal setting sense only, and not in terms of access to the same curriculum or social inclusion as their typically developing peers (Courtade et al., 2012).
Behavior Analysis in Practice
A subsequent push for inclusion beyond the physical environment led to research on effective models of inclu- sion targeting physical, social, and academic inclusion of individuals with disabilities (e.g., Ryndak et al., 1999). At the time, the belief was that the capabilities of students with severe disabilities were being downplayed by teaching vari- ous functional skills only, in lieu of providing them the right to the general curriculum content (Courtade et al., 2012). These inclusion efforts eventually led in part to the devel- opment of the Common Core State Standards Initiative (see CCSS, 2022), which were intended to ensure that all stu- dents were given the right to be prepared for postsecondary education and employment. These standards now require instruction across the United States to adhere to these stand- ards, which can, unfortunately, be in direct opposition to the instruction of more important adaptive behavior skills (see Ayres et al., 2011; Ayres et al., 2012).
However well-intended, the interpretation and follow- through of special education law seems to have taken some- thing of a misstep along the way. Current restrictions to teaching functional skills in place of common core standards are not in line with the early intents of various mandates. For example, The Rehabilitation Act of 1973 (as amended) stated that a disability, “in no way diminishes the right of individuals to: (a) live independently, (b) enjoy self-determi- nation, (c) make choices, (d) contribute to society, (e) pursue meaningful careers, and (f) enjoy full inclusion and integra- tion in the economic, political, social, cultural, and educa- tional mainstream of American society” (The Rehabilitation Act of 1973, 2010; see BACB, 2020, standards 2.01, 2.14, 3.01; core principles 1, 2). In addition, the Developmental Disabilities Assistance and Bill of Rights Act mandated that, “individuals with developmental disabilities have access to opportunities and necessary supports to be included in com- munity life, have interdependent relationships [and] access to and use of recreational, leisure and social opportunities to enrich their participation in community life” (Developmen- tal Disabilities Assistance and Bill of Rights Act of 2000; see BACB, 2020, standards 2.01, 2.14, 3.01; core principles 1, 2).
Likewise, the intent of IDEA was to provide access to the general education curriculum to the extent possible (emphasis added), with one of the purposes being to help all children, “be prepared to lead productive and independ- ent lives, to the maximum extent possible” (IDEA, 2004). It can be argued that the appropriateness and/or meaningful- ness of an educational program should be measured by the extent to which independent lives in adulthood are attained (Ayres et al., 2011; Lowrey et al., 2007). As Ayres et al. (2011) noted, “Learning fragments of higher-level academic skills should not be achieved at the cost of learning how to function independently in society” (p. 11). A standards- based focus in place of a functional/adaptive focus can be
detrimental to a learner; although grade-level achievement in academic skills may be possible with the help of behavior analysis and/or special education, it may not lead to more independent functioning and meaningful outcomes (Ayres et al., 2011). It is important to consider the cost of a curricu- lar focus that is not centered on individualized gains leading to improvements in quality of life in both current and future environments.
Insurance Coverage Funding Stream: Admirable Initial Achievements In comparison to education efforts that have spanned decades, the history of insurance funding for behav- ior analytic services is far less extensive. Early efforts in the field of applied behavior analysis at targeting skill acquisi- tion with individuals with disabilities date back to the late 1940s, with its origins in hospital settings (e.g., Ayllon & Haughton, 1962; Ayllon & Michael, 1959; Fuller, 1949; Isaacs et al., 1960). This was followed by the field of spe- cial education accessing this information and promoting its ability to teach new skills to children in a way backed by the science of behavior analysis (Staats & Butterfield, 1965; Wolf et al., 1963; Zimmerman & Zimmerman, 1962). In 1987, Lovaas et al. demonstrated the potential of behavior analytic intervention to teach autistic individuals new skills and, potentially, change their developmental trajectory (and thereby the cost of long-term intervention). This helped propel interventions based on the principles of ABA to the forefront of effective treatment for ASD, leading to the U.S. surgeon general supporting its use in early intervention as an evidence-based treatment (U.S. Department of Health & Human Services, 1999). Through the dedicated efforts of teams of professionals and advocates, insurance-funded coverage for autism became systematically mandated by law across all 50 states in the United States (Autism Speaks, n.d.b).
Despite these incredible gains that have enabled countless individuals on the spectrum access to an extremely valuable set of interventions, many insurance companies restrict funding to only those skills that meet a “medical necessity”3 criterion, which often includes only those with a direct connection to the DSM-V diagnostic criteria of ASD (e.g., social communica- tion/social interaction; restricted/repetitive patterns of behavior, interests, or activities, etc.; American Psychiatric Association, 2013). Although addressing these deficits is important, limiting intervention to these skill domains can result in practitioners
3 It should be noted that the American Academy of Pediatrics asserted that, “Medically necessary services generally are defined as being clinically appropriate, based on evidence and likely to produce incremental health benefits that justify their cost” (Giardino, 2022). Thus, the medical necessity designation is open to interpretation and, it can be argued, supports teaching skills outside of the ASD diag- nostic criteria that include vital adaptive behavior skills that promote independence.
Behavior Analysis in Practice
failing to target adaptive behavior skills that are necessary for success beyond childhood (Gerhardt et al., 2013). Thus, even if behavior analysts understand the importance of targeting meaningful skills that may positively affect outcomes, they may be restricted from doing so due to inadvertently restrictive practices promulgated by insurance companies and lawmakers. It would appear that the practical and financial benefits of tar- geting adaptive skills as early as possible in order to positively affect the long-term necessity (and cost) of services into adult- hood (Blaxill et al., 2021; Farley et al., 2009; Klin et al., 2007; Murphy et al., 2018; Zerbo et al., 2019) has not been adequately disseminated, or translated into general practice. As such, we have more work to do.
Focus on Early Identified Evidence‑Based Skills and Proce‑ dures The use of targets and procedures determined to be evidence-based for use with young children with autism may have been overgeneralized, and unintentionally contributed to the problem at hand. Early intensive behavioral interven- tion (EIBI), or the “Lovaas treatment approach” (Lovaas, 1987) has for decades been considered a well-established intervention for young children with autism (Eldevik et al., 2009; Odom et al., 2010; Rogers & Vismara, 2008; Wong et al., 2015). This approach has been described as featur- ing a variety of common elements (see Eikeseth, 2009; Green et al., 2002). Many of these features can be applied to adaptive behavior instruction in natural environments; these include: (1) individualized intervention that is com- prehensive across all skill domains; (2) use of numerous behavior analytic procedures used to build skills and reduce interfering behaviors; (3) parents as active co-therapists; (4) 1:1 teaching leading to effective small and large group for- mats; (5) intervention taking place in the home then gradu- ally transitioning to other relevant environments such as the community (Eikeseth, 2009; Eldevik et al., 2009; Green et al., 2002). However, many other features common to the typical behavior analytic approach used with autistic chil- dren may have less impact on adult outcomes. For example, this approach focuses on teaching skills within the normal developmental sequence, with goals of integration into gen- eral education settings once clients attain the skills required to function in those settings (Eikeseth, 2009; Eldevik et al., 2009; Green et al., 2002). Although this is appropriate for younger learners who may “catch up” to same-aged peers, for others, a focus on more adaptive behavior skills as early as possible would be far more effective in changing the trajectory of their lives. An overfocus on developmentally sequenced skills, for example, building block skills related to receptive language, matching, gross motor imitation, etc. that are commonly found in discrete trial teaching proce- dures for young children (often targeted in seated, table-top contexts), will not be appropriate in many cases following the early developmental years.
In addition, a number of skills-based assessments and curricula have been developed over the years in the field of behavior analysis (e.g., Partington, 2006; Sundburg, 2014) that, although valuable in many ways, seem to have also resulted in an overreliance on these tools by some practi- tioners to guide programming. When that happens, skills targeted for intervention are targeted based on their order or presence within the skills-based assessments and/or cur- ricula, and not upon their relevance to the student or their family. For myriad reasons, this can be inappropriate and ineffective. As a general rule, it appears that developmen- tally sequenced tools are often used in place of more func- tional skills-based tools, which may be more appropriate given a client’s need.
Furthermore, behavior analytic training that does not include flexibility, in-the-moment decision making, or an understanding of the client as a person and not simply a collection of behaviors may also result in rigid adherence to the use of published assessment tools and an overem- phasis on compliance instead of independence and self- determination (e.g., Leaf et al., 2016b), some of which has been at the root of our field’s negative perception (e.g., Bottema-Beutel et al., 2021; Shyman, 2016). This seems incompatible with various rights to exercise personal pref- erences and to live a life of competence, dignity, and qual- ity (e.g., Bannerman et al., 1990; Reid et al., 2017; Winnet & Winkler, 1972) or the clinical judgment skills that char- acterized early radical behaviorists who shaped our field (Leaf et al., 2016b, 2019).
Responsibility of Behavior Analysts in Contributing to a Solution: Ethical Requirements
Behavior analysts are in a position to help affect the neces- sary changes in adult autistic outcomes by targeting the right skills using the right procedures, and are ethically bound to do so. This is supported by the early outlines of our field that suggest that clients have a right to treatment that is highly individualized, teaches applied skills, promotes happiness and well-being, and supports favorable long-term/gener- alized outcomes (see Baer et al., 1968; Bannerman et al., 1990; Schwartz & Baer, 1991; Van Houten et al., 1988; Wolf, 1978) as well as empirical evidence that suggests that specific skills taught can affect outcomes (Eilenberg et al., 2019; Gerhardt & Lainer, 2011; Matthews et al., 2015; Shat- tuck et al., 2018). As will be reviewed in a later section, still relevant historical contributions and calls to action from related disciplines generally support the same values. These core values can be translated into practice guidelines that can be applied when serving all clients, starting at a young age,
Behavior Analysis in Practice
leading up to preparing for the transition to adulthood. Such guidelines are supported by the Ethics Code for Behavior Analysts (BACB, 2020).
In lieu of a separate BACB autism credential, or a sepa- rate Ethics Code for autism practitioners, our current ethical guidelines (BACB, 2020) can be interpreted as including recommendations for the promotion of best practice with autistic individuals, despite the Code not being designed for use with any one population/area. To support this, the Code (BACB, 2020) includes the following relevant and practi- cal statement: “The standards included in the Code are not meant to be exhaustive, as it is impossible to predict every situation that might constitute an ethics violation. There- fore, the absence of a particular behavior or type of conduct from the Code standards does not indicate that such behavior or conduct is ethical or unethical. When interpreting and applying a standard, it is critical to attend to its specific wording and function, as well as the core principles” (p. 5). Therefore, changes to the newest version of the Code (BACB 2020) are not directly suggested but, rather, it is recommended that members of our field consider extending its applications. As such, the overarching core principles, as well as a number of specific code standards, support recog- nition of the following proposed best practice themes that could help to improve outcomes for individuals with ASD whom we serve. The two major best practice themes pro- posed are: (1) What skill is targeted for acquisition? In other words, we need to be intentional in choosing what skills we target; and (2) How do we most effectively teach this skill? We need to be intentional and evidence-based when choos- ing how we teach these skills. Each of these themes will be described in detail in the following sections, with references made to both specific code items and core principles that support it.
Best Practice Theme #1: Intentionally Choosing What We Teach
To begin with, when interpreting our ethical guidelines, behavior analysts should be sure to recognize that references made to “behavior change” throughout the Code not only apply to behavior reduction programming, but also to skill acquisition programming. Although many BCBAs work in settings in which conducting functional analyses and writ- ing functionally related behavior plans to reduce and replace challenging behavior is their primary role, many others are responsible for their clients’ skill acquisition programming in one form or another. Although the Code emphasizes effec- tive treatment throughout its guidelines (see BACB, 2020, standards 2.01, 2.14, 2.18), it is important to remember that “Despite how evidence-based your interventions are, teaching inconsequential skills well is really no better than teaching essential skills poorly” (Gerhardt, 2008). In other
words, what we teach needs to be as important as how we teach. Acquisition of those skills that promote independ- ence in current and future environments has been linked to more positive outcomes for adults on the spectrum (Bolte & Poustka, 2002; Paul et al., 2004). Behavior analysts are able to help because (as previously stated) our science has decades of research supporting our ability to increase skills in these areas (e.g., Allen et al., 2010; Lambert et al., 2016; Matson et al., 2012; Van Laarhoven et al., 2010). Thus, if improved quality of life is (as it should be) the overall goal, then skill-acquisition programs should include interventions in complex areas of human competence such as independ- ence, safety, social skills, self-management, communication, time management, self-care, employment, etc., the acquisi- tion of which are generally associated with greater success in adulthood. In determining what to teach, practitioners should consider the diverse needs of the client, such as their chronological age, preferences, strengths, challenges, and the demands of current and potential future environments (see BACB, 2020, standards 2.01, 2.14, 2.15, 3.01; core principles 1, 2). Paraphrasing the criterion of ultimate func- tioning (Brown et al., 1976) discussed later, the standard to which we should hold skill acquisition for quality outcomes in adulthood is: “anything that if you can’t do, someone else will have to do for you” (Ayres et al., 2011). In choosing what to teach, using this criterion as our standard is a great way to start.
Although the Code instructs behavior analysts to provide services that maximize desired outcomes (i.e., BACB, 2020, standard 2.14), the interpretation of the term “outcomes” should be expanded to include outcomes that are general- ized over time and across various environments, especially as that pertains to adulthood. These outcomes are critically important when considering the long-term implications of treatment for which generalization is nonexistent. For exam- ple, learning to brush one’s teeth thoroughly is beneficial across the lifespan in that it enables less reliance on others, promotes good oral health, and prevents potential harm or risk that may come with the need for intrusive procedures such as going under general anesthesia to undergo a cleaning or cavity filling. In contrast, achieving mastery in labeling 200 pictures, only 100 of which they may encounter in real life, may provide few long-term, socially valid effects on the client’s life (not to mention, there is little evidence to sup- port generalization from labeling pictures to labeling real- life objects, e.g., Bak et al., 2021). In many cases, quality, not quantity should be emphasized when choosing goals that lead to socially valid, long-term outcomes.
In thinking about the prioritization of skills in decision making, practitioners can utilize various planning tools to help map out what skills are most relevant in terms of their long-term applications (e.g., Wehman & Kregel, 2020; Ford et al., 2005). For example, if a long-term goal is to live in a
Behavior Analysis in Practice
shared-living setting in adulthood, practitioners can back- ward-chain from this goal and systematically target skills across the lifespan that will get the client to this long-term outcome (Gerhardt & Bahry, 2022; Gerhardt et al., 2013; Ford et al., 2005; Wehman & Kregel, 2020). In this way, preparation for adulthood can begin as early as possible, with long-term thinking being conceptualized as, “adulthood begins in preschool” (Gerhardt, 2019). Identifying “check- points” to prompt the regular determination that progress is being made towards these long-term goals, and systemati- cally making adjustments to this plan as needed depending on progress (e.g., 5-year plans, 1-year plans, 6-month plans) is recommended (see BACB, 2020, standards 2.01, 2.09, 2.14, 2.15, 2.18, 3.01; core principles 1, 2).
Social Validity at the Center Behavior analysts should begin all programmatic decisions with social validity and quality of life in adulthood in mind, prioritizing client well-being and happiness (Green & Reid, 1996; Schwartz & Baer, 1991; Wolf, 1978; see BACB, 2020, standards 2.01, 2.09, 2.14, 3.01, 3.12; core principles 1, 2). After all, that was what behavior analysis originally pledged as its purpose—target- ing behaviors that matter to the individual (Baer et al., 1968; Wolf, 1978). The ethical behavior analyst recognizes that each autistic person is an individual, considers all aspects of the person and his or her environments, and seeks to change only those behaviors that are of social importance to both the individual and their family that will directly, or indi- rectly, improve their quality of life both now and in their future (Schwartz & Baer, 1991; Wolf, 1978; see BACB, 2020, standards 2.09, 2.14, 3.01, 3.12; core principle 1). Self-selection of priorities and self-determination are essen- tial values on which intervention is built and may more accurately reflect the wishes of the individual (see BACB, 2020, standards 2.09, 3.01, 3.12; core principles 1, 2). It is important to note that an effective skill acquisition program combines high-value and low-value targets, so behavior ana- lysts should take this into consideration as well. Skills that are valued by the individual are more likely to be maintained once they are acquired, but even skills that are not valued may be of importance in supporting engagement, compe- tence, enjoyment, and safety (Gerhardt et al., 2013).
In addition to the client themselves, the input of the par- ent and/or other family member(s) can provide an invaluable resource to selecting goals that matter. Familial input can help to ensure goals are meaningful, including providing opportunities to integrate cultural considerations and idi- osyncrasies of the client and family into practice (Ennis- Cole et al., 2013). In addition, family input may help to posi- tively affect the family’s quality of life. Related to adaptive behavior skills, a growing body of literature supports the importance of adolescents and adults achieving functional independence to support parental well-being (e.g., Cappe
et al., 2018; Fong et al., 2020; Lin, 2011). For example, Marsack-Topolewski et al. (2021) found that independence with completing various daily living skills was a statistically significant predictor of decreased caregiver burden. Thus, it would appear that a focus on specific skills that matter to both the client and the family can lead to improved outcomes for all consumers (see BACB, 2020, standards 2.01, 2.09, 2.14; core principles 1, 2).
Skill Acquisition Assessments and Curricula: Guides, Not Roadmaps Although not explicitly stated in the Code when referring to assessments, any interpretation of the word “assessment” should include both functional behavior assess- ments and skill-based assessments (see BACB, 2020, stand- ards 2.13, 3.01; core principle 1). Skill-based assessments can be useful in establishing a baseline level of skills from which progress can be tracked after the start of intervention. Choosing which assessment to use can have implications on the goals identified, so this decision should be made care- fully. Depending on each client’s unique needs, behavior analysts are encouraged to make individualized decisions, asking themselves a number of questions such as: How old is the client? Do they have an effective form of communi- cating their wants and needs? What are their greatest skill deficits? Do they engage in dangerous challenging behavior? How likely is it they will “catch up” to same-aged peers? Do they have the most essential/critical skills in their repertoire? What context-related demands are in place (e.g., city living vs. small-town living)? Depending on the answers to these questions and others, a decision can be made regarding what assessment/curriculum path to take (if any). In terms of avail- able skills-based assessments/curricula, these two paths can be thought of as developmental and functional.
In general, developmental assessments present skills in the order they naturally progress in typically develop- ing individuals, with an aim of bringing the client’s skill repertoire closer to that of same-aged peers (e.g., Verbal Behavior-Milestones Assessment and Placement Program [VB-MAPP]; Sundburg, 2014; Assessment of Basic Lan- guage and Learning Skills-Revised [ABLLS-R]; Partington, 2006). Developmental assessments/curricula can be benefi- cial when used with the right client (i.e., those who demon- strate a likelihood of catching up to these same-aged peers). However, because there are many other skills in addition to early learning developmental milestones that are vital to everyday independent living, practitioners should consider utilizing functional skills assessments and/or curricula as well (e.g., Essential for Living: A Communication, Behavior, and Functional Skills Curriculum, Assessment and Profes- sional Practitioner’s Handbook for Children and Adults with Moderate-to-Severe Disabilities [EFL], McGreevy et al., 2014; Community-Based Skills Assessment [CSA], Autism Speaks, 2014; also see Bondy, 2014), depending on
Behavior Analysis in Practice
each client’s individual needs. Although it is never too early to being targeting functional or adaptive skills, there is a time when it is too late. We must ensure that we are not pri- oritizing developmental milestones over critical skills that will have an impact on independence in current and future environments.
Skill-based assessments should be utilized with refer- ence to all relevant factors associated with promoting the best long-term outcomes for the client (see BACB, 2020, standards 2.01, 2.09, 2.13, 3.01; core principle 1). Targets should not be automatically chosen based on their sequential order or simple presence within a skill-based assessment. Instead, targeted skills should be highly individualized to what is most meaningful for that particular client. Clini- cal judgment should be used to make such decisions. For example, a 19-year-old client should not remain focused on seated table work labeling pictures of nouns and verbs for the sole purpose of increasing their number of acquired tacts to 200, thereby mastering Level 2 of the VB-MAPP (Sund- burg, 2014) when they cannot get dressed independently, use the bathroom without assistance, or engage in independent leisure skills safely. Filling in squares on assessment charts such as the VB-MAPP (Sundburg, 2014), AFLS (Partington & Mueller, 2016), ABLLS-R (Partington, 2006), etc. should not be the practitioner’s reinforcer; instead, individualized gains that are specifically meaningful to their lives should be the goal (see BACB, 2020, standards 2.01, 2.09, 2.13, 2.14, 2.18, 3.01; core principles 1, 2). Behavior analysts should also recognize that just because a goal came from a “functional” skills assessment does not mean that goal is necessarily functional for a particular client. For example, the AFLS (Partington & Mueller, 2016) may include a skill for zippering a jacket and although this is meaningful for someone who lives in the Northeast, if a learner lives in Southern California, zippering may not be important to their life, so it’s possible that valuable instructional time should not be wasted on it. In addition, if a unique need is brought up by the family or client themselves, this need should not be given less priority simply because the skill is not present within a skill-based assessment (see BACB, 2020, standards 2.01, 2.09, 2.13, 3.01; core principles 1, 2).
It is important to note that behavior analysts should not use the same assessments for every client. Instead, they should seek input from colleagues or continuing education opportunities to expand their assessment rep- ertoire. In some cases, implementing the same assess- ment with every client, without taking individual needs into account may constitute practicing outside of one’s competence (see BACB, 2020, standards 1.05, 2.13, 3.03; core principles 1, 4). For example, if a clinician has spent their career working with toddlers, and then uses the same assessment/curriculum with a teenage cli- ent, this would be inappropriate and result in a loss of
social validity for developed goals. As recommended in the Code, behavior analysts should only practice in new areas after they have received sufficient training, consul- tation, co-treatment, etc. from someone who is competent in that area (BACB, 2020, p. 9; see standards 1.05, 3.03, core principles 1, 4; BACB, 2020). In general, it would be ideal if assessment and curriculum development are best understood as independent processes; this helps to avoid the circular process of “teaching to the test” and allows for objective assessment and more meaningful curricula development. Assessments are not meant to be all-inclusive, and behavior analysts are encouraged to routinely think outside of the box. What is meaningful for some is not meaningful for all. Emphasis should be placed on using assessments as guides, not roadmaps in creating meaningful objectives for clients.
Best Practice Theme #2: Intentionally Choosing How We Teach
Along with choosing the right goals for skill acquisition programs, choosing the right interventions are also of pri- mary importance. First, in designing skill acquisition inter- ventions, behavior analysts should, of course, remember that what may be appropriate for younger learners may not be appropriate for older learners (see BACB, 2020, standards 1.05, 2.01, 2.14 3.01; core principles 1, 2, 4). For example, physical prompting may not be appropriate for teenagers or young adults in the same way it may be for toddlers. Additionally, behavior analysts should speak and behave in ways that reflect dignity for all, with specific attention given to how interactions should shift when work- ing with adults (Reid et al., 2017). Although less extensive when compared to younger learners, there is a growing body of research that supports the use of behavior analytic intervention with older individuals with ASD (Roth et al., 2014) including such procedures as modeling (Allen et al., 2010), chaining (Lambert et al., 2016), prompting (Van Laarhoven et al., 2010), differential reinforcement (Siga- foos et al., 2009), and shaping (Shabani & Fisher, 2006), all of which can be used to teach highly important adaptive behavior skills relevant into adulthood. It is important that these core behavior analytic procedures be used to ensure that the correct procedures to target the most meaningful goals are used, in order to benefit the learner (see BACB, 2020, standards 1.05, 2.01, 2.14, 3.01; core principles 1, 2, and 4). In particular, considerations should be made to the following areas: (1) the context in which instruction takes place; (2) the intensity of instruction necessary for the skill to be acquired; and (3) the efficiency of instruction, such that the least amount of response effort to be effective is required (Gerhardt et al., 2013).
Behavior Analysis in Practice
Context Teaching those complex skills associated with competent adulthood most often means using real materi- als and teaching in real environments. Brown et al. (1976) noted:
However cumbersome, time consuming, inconven- ient or expensive it may be to do so, the pegs, felt squares, pictures of money, tokens, pictures, edible consequences and many, if not all, of the commer- cially available kits and irrelevant paper and pencil tasks should be faded out. Real money, real streets and cars, real people, real stores, real sounds and smells, real tools and objects, real group homes, real world settings, real appliances and utensils, real motor skills and real ridicule, rejection, and disappointments must replace them. (p. 14)
Despite this call to action over 45 years ago, pegs, pic- tures, tokens, and edibles continue to run rampant in skill acquisition programming within the fields of special educa- tion and applied behavior analysis, with seemingly little con- sideration of the detrimental long-term outcomes of using methods and materials that fail to generalize (see Bak et al., 2021). Because generalization often does not occur with- out being directly programmed for in individuals with dis- abilities, including ASD, it is to the benefit of the learner for teaching to take place in the environment where the skill will ultimately take place (Gerhardt et al., 2013; MacDuff et al., 1993; Neely et al., 2016; Phillips & Vollmer, 2012; Stokes & Baer, 1977). Although sometimes mock materials or con- trived environments may be necessary for certain skills and/ or certain learners initially, practitioners should ensure that this is a stepping stone and not an endpoint; efforts should be continually made towards using real materials in real environments, with changes being made to programming as needed to promote efficient outcomes (see BACB, 2020, standards 2.01, 2.14, 2.18; core principles 1, 2).
Targeting complex community-based skills in the natural environment, and not just seated at a desk in contrived envi- ronments is critical (Gerhardt & Lainer, 2011; Steege et al., 2007). For example, instruction in completing a purchasing routine requires the use of shaping, prompting, and differ- ential reinforcement in the community where the reinforcer is the item they are purchasing, as opposed to seated in a classroom or clinic using conventional discrete trial teaching (DTT; Leaf et al., 2016a) and reinforcing with tokens (e.g., mass trials of “this bag of chips cost $2, you have $4, do you have enough money?”). Teaching adaptive behavior skills in natural environments may necessarily be more complex given the high level of uncontrollable variables that exist in natural environments (e.g., distracting sounds, unpredictable interactions of community members, unexpected changes in routines). Variables such as the level of complexity of the
skill being taught may influence both the components and duration of training needed for those who will implement these procedures (Rispoli et al., 2011). As such, behavior analysts should ensure training takes place in these complex environments with all necessary trainees, including non- behavior-analytic staff such as those in other disciplines, as well as families who may aid in the teaching of certain skills for generalization (see BACB, 2020, standards 4.02, 4.06; core principles 1, 2, 4). Although important in all behavior analytic programming, this necessitates training to include progressive approaches that emphasize responding to the behavior of the individual, assessing reinforcer preferences in the moment, and making quick decisions to adjust pro- gramming, as needed (Leaf et al., 2016b; see BACB, 2020, standards 1.05, 2.01, 2.14, 2.18; core principles 1, 2, 4).
Intensity Individuals with ASD often require a certain level of instructional intensity to master skills. Although this appears to be widely accepted based on the intensity with which seated-at-a-desk DTT trials are often run in controlled settings (e.g., 10 trials per skill, per session), behavior analysts need to generalize this understanding to important adaptive skills that require teaching in natural con- texts, such as the community (Gerhardt et al., 2013; Linstead et al., 2017). Community-based instruction has a substantial research base (Walker et al., 2010) that supports its use with individuals with disabilities. We cannot reasonably expect clients to master community-based objectives by providing an insufficient number of practice opportunities each week (e.g., Almalky, 2018; Pickens & Dymond, 2014). In settings that have restrictions on teaching in natural environments, behavior analysts must work to advocate for sufficient prac- tice to be afforded, if we expect learners to master important adaptive behavior skills that will be relevant in adulthood (see BACB, 2020, standards 2.01, 2.14, 2.15, 3.12; core principles 1, 2, 4).
Efficiency In terms of efficiency, behavior analysts should also ensure that programming targets community-accepted rates, latencies, and durations (Brown et al., 1976). This aspect of social validity is extremely important. For exam- ple, when teaching grocery shopping, it may be most appro- priate to ask a cashier in a store what they think the most important customer skills are. It is typical, although not exclusively, that this might include the speed with which a customer produces their credit card and pays for their items. In this case, fluency and short duration should be prioritized in training (see BACB, 2020, standards 2.01, 2.14, 2.18; core principles 1, 2, 4).
At a minimum, workaround adaptations should always be considered to decrease the response effort of skills intended to increase the likelihood and speed with which skills are mastered (Gerhardt et al., 2013). This is especially important
Behavior Analysis in Practice
if most society members use these adaptations regularly, particularly by making use of the most updated technolo- gies. For example, teaching purchasing using a credit card, gift card, or Apple Pay instead of spending years teaching the value of coins/bills with the aim of teaching purchas- ing using cash, using shortcuts in a smartphone to make a voice or video call instead of memorizing phone numbers, making use of a phone’s global positioning system to find directions home instead of memorizing how to get to loca- tions, or using ride share applications instead of teaching a complicated public transportation skill (see BACB, 2020, standards 2.01, 2.14, 2.18; core principles 1, 2, 4).
Although data-based decision making is a regular part of behavior analytic practice (Baer et al., 1968; Slocum et al., 2014) behavior analysts should not only make pro- cedural changes when the data prove current interventions are ineffective, but also make decisions to modify an objec- tive to yield the desired outcome more quickly (see BACB, 2020, standards 2.01, 2.14, 2.18; core principles 1, 2, 4). For example, if a learner has spent a significant amount of time working on tying their shoes with limited success, there are numerous adaptations that can be made to still allow them to independently complete the task of putting on one’s own shoes (e.g., elastic/drawstring shoelaces, stylish slip-on shoes). Likewise, if a learner is struggling with the step of using a washing machine that includes filling a cup of liquid laundry detergent, a commonly used adaptation such as Tide PODS® could be used to circumvent this difficulty and more quickly lead to independence. Efficiency should be prior- itized so that skills can be quickly mastered, and new skills can be targeted. Practitioners have such little time during childhood and adolescence to affect outcomes in adulthood, simply in terms of years of available intensive and funded treatment (Marsack-Topolewski & Weisz, 2020; Shattuck et al., 2020). We do not have time to waste.
Individual Responsibility in Interpreting the Ethics Code vs. Necessary Systemic Changes
The previous sections described how behavior analysts can help to improve outcomes in adulthood for those on the autism spectrum by shaping their practice around pro- posed ethical themes that are supported by the current Code (BACB, 2020). In addition to individual responsibility to uphold these best-practice themes, it is proposed that sev- eral systemic changes to our field could help support these improvements in practice. First, we can provide prospective and current behavior analysts with resources such as this article, as well as texts or ethical handbooks that could be developed to go hand in hand with the Code that include spe- cific attention to how to guide skill acquisition programming as it relates to improving long-term outcomes of adolescents
and adults with ASD. Because it would be helpful if funding sources were mandated to support adaptive behavior skills that have been shown to positively affect outcomes, it would be beneficial to also resource behavior analysts, ABA-busi- ness owners, billing specialists, etc. with a curated collection of research to refer to that supports the benefit of adaptive behavior skills (e.g., Bolte & Poustka, 2002; Dell’Armo & Tassé, 2019; Paul et al., 2004), the effectiveness of ABA with older learners (e.g., Ivy & Schreck, 2016), as well as research that supports teaching such skills in natural envi- ronments (e.g., Cowan & Allen, 2007) to aid in their efforts to advocate for funding to support these important skills. Additional research would be helpful to add to the small but emerging literature base in these areas, including large- scale randomized controlled trials or longitudinal outcome studies to support efforts in advocating for more funding and resources across the lifespan. Second, we can provide more forums to facilitate the exchange of this information and net- working opportunities to allow behavior analysts to discuss and expand their knowledge in these areas, including plat- forms to connect practitioners with experts who may provide consultation and/or mentorship, special interest groups, as well as focused continuing education opportunities to further disseminate these points.
Third, all of the concerns discussed earlier are directly relevant to training the future of our field. If behavior ana- lysts who work with individuals with ASD do not practice in ethical ways that promote improved outcomes for this population in adulthood, they will not be able to train the next cohort of behavior analysts to do so (see BACB, 2020, standards 4.02,4.06; core principle 4). If we want to ensure best practice in the field within this population, it may make sense to consider making modifications to adjust the trickle-down effect that determines what behaviors end up in newly minted BCBAs’ repertoires who intend to work with individuals with autism. For example, the BACB task list determines what is on the BACB exam, which drives higher education course requirements, supervision guidelines, etc., yet there are no current requirement that specific expertise be developed to work within the autism population, and (as previously stated) this is where three quarters of our field practices (BACB, 2020).
Historically Relevant Contributions that Are Not Being Reliably Applied in Behavior Analytic Practice
What is interesting about the suggestions made within this article is that they do not represent values or ideas that are inherently “new.” Various calls to action have been pub- lished, and practice movements have taken place both within the field of applied behavior analysis and in related
Behavior Analysis in Practice
disciplines that support the rights of individuals with dis- abilities, including autism, to be taught the applied, socially validated skills needed to function independently in adult- hood. Yet, these efforts seemed to have lacked sufficient impact, because little improvement in the outcome data has been noted. Some of these contributions are discussed in the following sections. The reader is encouraged to note the parallels that can be seen between these sections and what the authors have proposed in the present article, and consider historical contributions as additional support to this article’s purpose.
Behavior Analytic Contributions
Over 5 decades ago, the central importance of targeting and prioritizing functional skills and honoring the rights of cli- ents was put forth in our peer-reviewed literature. First, in what is often referred to as the defining article of our field, Baer et al. (1968) asserted that behavior analytic work should result in strong, socially significant, and generalizable out- comes; this surely applies to a focus on positive, long-term outcomes in adulthood (see BACB, 2020, standards 2.01, 2.15, 2.18, 3.01; core principles 1, 2). Related to choosing goals and procedures that matter, Wolf (1978) defined the concept of social validity and urged the field that that society should validate our interventions on at least three levels: (1) the goals we prescribe; (2) the procedures we use; and (3) the effects of treatment (p. 206; see BACB, 2020, standards 2.01, 2.14, 2.15, 3.01; core principles 1, 2). He further argued that as an applied science, we should target only those skills most important to people, and be “dedicated to helping people become better able to achieve their reinforcers" (Wolf, 1978, p. 106). Numerous authors over the years provided extensive guidelines for how to measure social validity and translate the results of these measurements into practice that are still appli- cable today (e.g., Bernstein, 1989; Fawcett, 1991; Gresham & Lopez, 1996; Kazdin, 1980).
In addition, Van Houten et al.’s (1988) seminal article (“The Right to Effective Behavioral Treatment”) outlined six rights to which all recipients of behavior-analytic intervention are entitled. Of these rights, at least two directly relate to selecting goals that are relevant to improving outcomes in adulthood; these include, “The right to services whose overriding goal is personal welfare,” and “The right to programs that teach functional skills” (p. 382). Regarding personal welfare, Van Houten et al. (1988) stated, “The primary purpose of behavioral treatment is to assist individuals in acquiring functional skills that promote independence. Both the immediate and long-term welfare of an individual are taken into account through active participation by the client or an authorized proxy in making treatment-related decisions" (p. 382) (see BACB, 2020, stand- ards 2.01, 3.01; core principles 1, 2). In describing the right to functional programs, the authors noted that the ultimate goal of
behavioral services is to help ensure the individual can function effectively in their immediate environment, as well as within society (p. 82). Likewise, Bannerman et al. (1990) argued for the rights of individuals with disabilities to exercise personal liberties, explaining that all have the right to, “eat too many doughnuts and take a nap” (p. 80). Paramount within these rights is the freedom that should be afforded to exercise choice within one’s own programming and exert control over one’s own life. This included having input into what skills will be taught and how (see BACB, 2020, standards 2.01, 2.13, 2.14, 3.01; core principles 1, 2). In addition, the authors argued for teaching independent living skills and other functional, pre- ferred behaviors (Bannerman et al., 1990).
Contributions from Related Disciplines
Researcher-practitioners such as Lou Brown and colleagues provided valuable insight into the early navigation of what and how to teach individuals with disabilities after inclu- sion efforts began in the United States (O’Brien & O’Brien, 2000). It is notable that, as previously mentioned, in 1976 Brown et al. described what was referred to as the criterion of ultimate functioning as, “the ever-changing, expand- ing, localized, and personalized cluster of factors that each person must possess in order to function as productively and independently as possible in socially, vocationally, and domestically integrated adult community environments” (p. 8). Such a standard by which to measure the importance of goals to target provides a valuable example that can still be called upon today. Some, although surely not all, additional contributions related to several movements within the spe- cial education/disability fields that can be called upon for support and guidance for affecting quality outcomes will be reviewed in the following sections.
Person‑Centered Planning Person-centered planning approaches were first developed in the late 1970s to the early 1990s in order to help practitioners develop collabo- rative, goal-oriented, individualized programs to support all people, regardless of their level of disability (Keyes & Owens-Johnson, 2003; O’Brien, 1987). Common agendas of the first person-centered planning approaches included: increasing choice, advocating depersonalizing labels and dif- ference-making procedures, honoring the voices of the per- son and those who know the person best, building relation- ships, individualizing support based on high expectations, and demanding that agencies adopt new forms of services (O’Brien & O’Brien, 2000; see BACB, 2020, standards 2.01, 2.09, 2.14, 2.15, 3.01; core principles 1, 2). These efforts sought to develop skills and knowledge needed to support a quality life in the community for all individuals, with collaborative efforts focused on community presence, par- ticipation, positive relationships, respect, and competence
Behavior Analysis in Practice
(Claes et al., 2010; O’Brien & O’Brien, 2000). Analysis of the research in person-centered planning suggested that this approach has had a positive, but moderate, impact on personal outcomes (Claes et al., 2010). Thus, the values and efforts of person-centered planning approaches that were put in place decades ago are clearly in line with the values of an ethical behavior analyst and the intentions of the field of behavior analysis to value and benefit the individual (see BACB, 2020, standards 2.01, 2.09, 2.14, 2.15, 3.01; core principles 1, 2).
Positive Behavioral Supports (PBS) From its beginnings, positive behavior supports (PBS) has focused on targeting skill acquisition goals that promote meaningful outcomes and quality of life for individuals with disabilities, includ- ing those with autism and their families (Carr et al., 2002). PBS emerged in the mid-1980s as an alternative to the pre- vailing ABA practices that emphasized the manipulation of consequences, often aversive, to produce behavior change (Kincaid et al., 2016). Carr et al. (2002) defined PBS as "an applied science that uses educational methods to expand an individual's behavior repertoire and systems change meth- ods to redesign an individual's living environment first to enhance the individual's quality of life and, second, to min- imize his or her problem behavior" (p. 4). PBS relies on strategies that are respectful of a person's dignity and overall well-being, drawn primarily from behavioral, educational, and social sciences that include progress monitoring at the individual level and at the larger systems level (e.g., families, classrooms, schools, social, service programs, and facili- ties; Meyer et al., 2021; Pinkelman et al., 2020; see BACB, 2020, standards 2.01, 2.09, 2.14, 2.15, 2.18, 3.01; core prin- ciples 1, 2). It has been suggested that PBS is a framework for applied behavior analytical practices at scale (Horner & Sugai, 2015) that is important for behavior analysts to understand because it provides a data-based framework to improve the effectiveness and efficiency of applied behavior analysis interventions (Putnam & Kincaid, 2015). Although keeping the rigor of our science intact, it would appear that examining the relevant contributions of PBS could be help- ful to behavior analysts today seeking to provide meaningful treatment for individuals on the spectrum (see BACB, 2020, standards 2.01, 2.09, 2.14, 2.15, 2.18, 3.01; core principles 1, 2).
Self‑Determination In the 1990s, an educational emphasis was placed on promoting self-determination, which emerged from federal initiatives mandating active student involve- ment in transition goals, educational planning, and decision making for adolescents with disabilities (Wehmeyer, 1998; Wehmeyer & Schalock, 2001). An evolving definition of self-determination was proposed by Martin and Marshall (1995) that included knowing how to choose; knowing what
one wants, how to get it, and being assertive in doing so; evaluating progress towards goals; and adjusting perfor- mance to attain these goals (Wehmeyer & Schalock, 2001; see BACB, 2020, standards 2.01, 2.09, 2.14; core princi- ples 1, 2). Wehmeyer and Schalock (2001) suggested that one of the reasons adults with disabilities have poor out- comes (e.g., employment, independent living, community integration) after leaving school is because they have not been adequately prepared to become self-determined. Self- determination behaviors were identified as a valid outcome measure and closely related to higher QoL (Wehmeyer & Schwartz, 1997). In an effort to describe self-determination in behavioral science terms, in particular for those with less developed verbal skills, Baer (1998) stated simply. “The pro- posal is to find out what people with severe disabilities want and to incorporate as many of their wants as feasible.... The proposal is to develop our sensitivity to the various forms of communication used by people with severe disabilities so that we may do more of what they want and impose on them less of what we assume they want or want them to want” (p. 51). Although the concept of self-determination was emphasized in the 1990s, advocates for those with dis- abilities began emphasizing the ability to be self-determined as early as the 1970s (Ward, 2005). For example, Perske (1972) discussed that individuals of diverse abilities have the right to the dignity of risk and discussed how situations involving appropriate and reasonable risk can, and should, be incorporated into meaningful programming (see BACB, 2020, standard 2.15; core principle 1, 2). Thus, a focus on independence in making choices (at any level of ability) that leads to increased QoL was put out in the literature dating back decades; this remains relevant today in developing pro- gramming that leads to improved adult outcomes.
Summary
Over the next decade, it is estimated that an additional 707,000–1,116,000 teens will enter the world of adult- hood (Autism Speaks, n.d.a). Despite these ever-increasing numbers, outcomes for adults on the spectrum remain poor, research remains slim, funding remains low, and resources remain allocated elsewhere (Gerhardt & Lainer, 2011; Howlin, 2021; Shattuck et al., 2020). However, while the number of adults on the spectrum continues to increase, so does the number of BACB certificants (BACB, n.d.). The field of behavior analysis is in a position to help and, it can be argued, is ethically required to. Behavior analysts are encouraged to change the way we practice, by (1) making needed modifications to what skills we teach, prioritizing those skills that are most meaningful for our clients’ lives both now and in their future; and (2) ensuring that the most effective procedures are used to teach the most important
Behavior Analysis in Practice
skills. In order to affect change, modifications should be made not only on an individual practitioner level, but also on a larger scale through resourcing behavior analysts and other advocates of our field with relevant research, providing forums for dissemination and networking, and shaping the future of our field by ensuring specific expertise is developed in those behavior analysts who choose to work within the autism population. The authors hope that this article will be used as a resource to aid in supervision and/or coursework, or as a guide in creating continuing education content. It is also the hope that this article will shed light on a real prob- lem within the primary population served by the field of ABA, sparking interest that may lead to more research and practice within this population. Finally, it is the hope of the authors that this article will build on work done previously and serve as a point of renewed refocusing toward prioritiz- ing meaningful treatment that leads to improved outcomes in adulthood for individuals with ASD.
Authors' Contributions The first draft of the manuscript was written by Shanna Bahry and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
Data Availability Not applicable.
Code Availability Not applicable.
Declarations
Conflicts of Interest/Competing Interests The authors have no con- flicts of interest to declare that are relevant to the content of this article. Additional declarations related to ethics/consent are not applicable, because this article did not involve the use of human and/or animal participants.
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- The Ethics of Actually Helping People: Targeting Skill Acquisition Goals That Promote Meaningful Outcomes for Individuals with Autism Spectrum Disorder
- Abstract
- The Problem of Poor Adult Outcomes and Adaptive Behavior Skills as the Solution
- Historical Context to How We Got Here: Unintentional Contributions to the Problem
- Responsibility of Behavior Analysts in Contributing to a Solution: Ethical Requirements
- Best Practice Theme #1: Intentionally Choosing What We Teach
- Best Practice Theme #2: Intentionally Choosing How We Teach
- Individual Responsibility in Interpreting the Ethics Code vs. Necessary Systemic Changes
- Historically Relevant Contributions that Are Not Being Reliably Applied in Behavior Analytic Practice
- Behavior Analytic Contributions
- Contributions from Related Disciplines
- Summary
- References
