Serving students with autism: Ensuring a place for applied behavior analysis

Why have schools been reluctant to provide this evidence-based intervention for students with autism?

Autism spectrum disorder (ASD) has become an increasingly common diagnosis in recent years, raising the pressure on schools to determine the most effective way to meet the needs of this fast-growing student population. The Centers for Disease Control and Prevention reports that, today, one in 44 children is diagnosed with ASD (Maenner et al., 2021), representing a steady rise over previous decades. ASD is defined by the Individuals with Disabilities Education Act (IDEA, 2004) as a developmental disability significantly affecting verbal and nonverbal communication and social interaction; it is generally evident before age 3 and can adversely affect a child’s educational performance. This federal definition also includes some of the traits common to the condition: repetitive activities and stereotyped movements, resistance to environmental change or alterations to daily routines, and unusual responses to sensory experiences.

The degree to which these behaviors manifest can vary widely, with some children being considered high-functioning and others being affected severely (Dillenburger et al., 2010). Schools have a responsibility under IDEA to provide appropriate services for students all along this spectrum. But as the number of autism diagnoses has increased, many school districts have struggled to educate students with autism who require a high level of support and related services delivered by professionals with specialized expertise (Stevenson & Correa, 2019).

Understanding applied behavior analysis

Researchers have found applied behavior analysis (ABA) to be one of most the effective means of supporting children with autism spectrum disorder (Dillenburger et al., 2010; Fein et al., 2013), and over the last four decades, approaches based on ABA have proven to be successful at mitigating behavioral challenges and improving communication, socialization, intellectual functioning, language skills, and daily living skills (Swanson & Sachse-Lee, 2000; Virués-Ortega, 2010). Generally applied early in the child’s development, these approaches offer comprehensive, individualized services, both in one-on-one and small-group settings, in combination with parent training (Virués-Ortega, 2010). Moreover, ABA techniques can provide supports that enable many more students with autism to be successfully educated with their neurotypical peers (Dawson et al., 2012; Eapen, Črnčec, & Walter, 2013). For these reasons, educators, service providers, and parents in public school settings frequently request ABA-based interventions for children with autism (Hess et al., 2008).

Today’s ABA is aimed at teaching functional and appropriate alternatives to challenging behavior and promoting a child’s independence while respecting their neurodiversity.

Among some educators and advocates, ABA has a controversial reputation, stemming from some of its past practices — in its early years, it employed lengthy, demanding, and sometimes unenjoyable tasks (e.g., sitting at a table and being drilled with flashcards), and it sometimes relied on punishing children’s negative behaviors (Child Mind Institute, n.d.). Today’s ABA, on the other hand, is aimed at teaching functional and appropriate alternatives to challenging behavior and promoting a child’s independence while respecting their neurodiversity. ABA focuses on identifying and managing those behaviors that interfere with daily life, rather than trying to eliminate every behavior associated with autism. For example, although “stimming” behavior (i.e., repetitive motions, such as hand-flapping) may pose issues when it comes to social acceptance, this behavior serves a purpose for children with autism, who may experience heightened sensory responses to their environment. For them, stimming may be a way to help manage energy and self-regulate. The point of ABA therapy is for the child to learn useful skills for managing their behavior using activities they find motivating (Simpson, 2001).

While it relies on a wide range of situation-specific techniques, ABA’s basic strategy is to identify antecedents (what happens before children engage in a particular behavior) and consequences (what happens immediately after they engage in that behavior). Professionals typically use a process called the “ABCs of behavior” (for antecedent, behavior, and consequence) to determine what is triggering and maintaining the child’s behavior, identify any patterns that emerge, and understand the purpose the behavior serves for the child. Then, the provider can select, teach, and reinforce an appropriate replacement behavior that meets the same need for the child (Sugai et al., 2000).

For example, consider a scenario involving a younger student with ASD who has some expressive language but has trouble asking for things he wants or needs appropriately. He is often observed yelling to get an adult’s attention to make his needs known. Using observations and assessments of his preferences, his therapist has determined that he enjoys playing with Legos, so she begins incorporating them into his work on communication skills. During play, as the child builds a tower, the therapist places some of the Lego pieces slightly out of reach, creating a situation where it is natural for the child to ask her to pass him a piece. As soon as he attempts to make an appropriate gestural or verbal request (with or without prompting), the therapist gives him a Lego. Over time, she will continue modeling the desired language and reinforcing the boy’s attempts as he gets closer and closer to the target goal (moving, for example, from making a request with a gesture to using words), using activities and items that motivate the child. The therapist might also target multiple skills at once. For instance, if another goal is to practice the naming of colors, she might ask the boy, “Would you like the red or blue Lego?” In short, the learner receives an abundance of positive reinforcement for demonstrating target skills and socially appropriate behaviors. The emphasis is on positive social interactions and child-led learning, with teaching opportunities constructed around what the child likes or wants to do, which helps keeps them motivated and engaged.

The reluctance to implement ABA

There are compelling reasons why parents, even those who can afford to pay for treatment outside school, might want schools to deliver ABA interventions to their children. For the approach to be effective, students must be able to apply what they are learning across all environments, in multiple situations, and with various people (Hart & Whalon, 2008). Because school-age children spend so much of their day at school, schools constitute a natural environment for them to learn and practice new skills. And when they learn these skills at school, they are better able to apply them in that setting, thus supporting their academic learning as well.

However, despite the documented efficacy of ABA-based interventions, and despite the positive and student-centered nature of today’s interventions, many public school systems have been reluctant to implement them (Stahmer, 2005). Observers cite a number of reasons for this (Boe, Cook, & Sunderland, 2008), including school administrators’ limited knowledge about the approach, the scarcity of qualified ABA professionals and teachers, and the fact that very few teacher education programs include coursework on effective teaching strategies for students with autism (Morrier, Hess, & Heflin, 2011; Hess et al., 2008). Perhaps the greatest deterrent for district leaders, though, is the expense of these services (Hill, Martin, & Nelson-Head, 2011).

Indeed, these interventions are quite resource-intensive. Instructional plans must be designed and monitored by a specially trained and board-certified behavior analyst (BCBA), who conducts a detailed assessment and then tailors the program to each learner’s skills, needs, interests, and preferences. The BCBA breaks down the skills identified for intervention into small, concrete steps, and the therapist teaches those steps one at a time, moving from simple (e.g., imitating single sounds or words) to more complex (e.g., engaging in a conversation). Also, the BCBA and therapist collect data in each therapy session to monitor the child’s individual progress, and the BCBA regularly meets with the family and program staff to review data, plan ahead, and modify teaching plans and goals as needed. Further, ABA therapy should be customized to the specific child’s needs and can take 10-25 hours a week for a treatment focused on just a few behaviors and 30-40 hours a week for treatments addressing a large number of behaviors (Council of Autism Service Providers, 2020).

As the number of autism diagnoses rises, the costs of implementation will continue to climb just as steadily — ABA services become no less expensive as they scale up, since they require one-to-one or small-group work (Virués-Ortega, 2010). Further, it will become increasingly difficult to hire and retain personnel who are trained to develop and oversee ABA programs. Today, there are roughly 30,000 BCBAs in the U.S., which is only about half the number required to meet current needs (Butterfly Effects, 2019).

Given these challenges, school district leaders face considerable pressure to avoid having to provide ABA-related services (Decker & Hurwitz, 2018). The evidence may support those services, and parents may demand them, but providing them is difficult and expensive.

The legal struggle

The most important question has yet to be resolved: Are public schools required to provide these interventions (no matter the cost)? Under IDEA, students with disabilities have a right to “related services” to help them learn and achieve the maximum benefit from their education. Such related services are to be based on peer-reviewed research, and they are to consist of “transportation and such developmental, corrective and other supportive services as are required to help a child with a disability benefit from special education” (§300.34). Related services as defined by IDEA may include audiology, counseling services, occupational therapy, physical therapy, speech therapy, psychological services, early identification and assessment of disabilities, parent training, recreation, school health services, mobility services, and transportation, among others. And while IDEA does not specifically list ABA programs as a related service, the law does not limit such services to those expressly mentioned in the regulation. By default, if a student needs a specific developmental, corrective, or supportive service in order to benefit from special education, then it is considered a related service and should be provided. For example, if a child needs a full- or part-time aide or an assistive technology to benefit from their course of study, then that service must be included in the child’s individualized education program (IEP).

Still, ABA’s status as a required intervention remains unclear. IDEA explicitly states that schools must provide eligible students with ASD a free and appropriate public education, but families and school districts have long been at odds over how to define “appropriate” (Decker & Hurwitz, 2018). And while a wealth of research evidence suggests that applied behavioral analysis is, in fact, both appropriate and beneficial, courts have taken a hands-off approach when deciding whether schools were legally required to provide ABA services (Decker, 2017).

However, the 2017 U.S. Supreme Court ruling in Endrew F. v. Douglas County School District appears to tilt the balance in favor of families who want their schools to provide ABA treatment. The Endrew case concerned a child with ASD who was not making progress after several years in public schools. His IEP largely carried over the same basic goals and objectives from one year to the next, indicating that he was failing to make significant improvements. The Court affirmed IDEA’s intent that children with disabilities not only reach minimal standards but make meaningful progress in their education and achieve challenging, individualized objectives (Yell & Bateman, 2017).

Further, although previous court rulings have suggested that students with autism did not have a right to any particular method, including ABA (Stevenson & Correa, 2019), recent due process cases, litigation, and legislation in states such as Louisiana, Hawaii, and Oregon have shined a light on the growing evidence for ABA as the most effective approach for students with ASD (Hart Barnett, Zucker, & More, 2021). And as they become more familiar with federal and state laws and relevant judicial decisions, many more parents will likely pursue legal avenues to advocate for their children’s access to ABA treatments.

Moving forward together

IDEA is clear in affirming the importance of parent-school collaboration in education programming for students with disabilities. And when it comes to meeting the needs of children and adolescents with ASD, the research shows that this collaboration should include not just parents and teachers but also ABA-trained therapists and healthcare providers. While therapists will be the ones to provide the ABA services, the research also suggests that teachers and other school staff should receive some basic training in this approach, so that they know how best to support their students.

But while we have strong evidence as to the benefits of applied behavioral analysis, researchers have not yet provided much guidance on the best ways to manage these partnerships, provide the necessary professional development, and deliver school-based ABA effectively and efficiently, perhaps lowering the cost of these interventions. Whether parents or school districts ultimately prevail in litigation over ABA services, cost concerns will likely remain front and center for school system leaders — not only because they might be forced to provide expensive services but also because the lawsuits themselves tend to be quite expensive (Decker & Hurwitz, 2018). All the more reason for researchers and policy makers to work together to find smart, evidence-based ways to deliver high-quality ABA-based services at a lower cost. All of us — students, parents, teachers, ABA providers, school and district leaders, and policy makers — share a vested interest in doing so.

 

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This article appears in the March 2022 issue of Kappan, Vol. 103, No. 6, pp. 27-31.