1 Clinical Applications of ABA Applied Behavior Analysis is the application of scientific approaches to shape and improve certain behaviors and skills such as communication, reading, hygiene, motor skills, grooming, and social skills. It is especially effective for children and adults who have psychological disorders that inhibit their ability to adapt effectively to society. In the case of Kaitie, an autistic four-year-old, one of the most effective ABA strategies is a home Program that will run for 15 hours a week. These services will be provided by two Registered Behavior Technicians (RBTs). It will also involve training the child’s parents to ensure that they reinforce the skills and behaviors learned during therapy. Kaitie’s parents are hesitant to adopt the home Program because they would like it to include Facilitated Communication, which they believe would help Kaitie improve her language development. In three parts, this paper discusses the importance of the home Program treatment strategy, and the merits that it would have on Kaitie’s development.
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2 Part One: Developing a Rapport Parental involvement plays a crucial role in enhancing the success of ABA therapy. When the parents of an autistic child collaborate with BCBAs and RBTs, it augments the lessons they learn in therapy, thus enhancing the child's progress and skills (Behavior Analyst Certification Board, 2017).However, it is often challenging for BCBAs and RBTs to get the support of parents in the Program since they might have contradicting opinions about the most effective strategy for their child. The key to dealing with resistant clients and getting more clients involved in the Program is training. This is known as family guidance or parent training. Parents and caregivers bear the responsibility of enforcing the skills and behaviors that will guide the child to leaving a better life. It can be difficult to get the support of parents because they also have a plan for the child that they believe would be more effective. To deal with Kaitie’s parents as resistant clients, it is important to work with them collaboratively instead of approaching them from a client-expert perspective. Parents play a crucial aspect in the child’s progress because they know the child's history and would help the child learn and grow. When approaching Kaitie's parents, as the BCBA, I should avoid dealing with them from an expert standpoint and discuss the treatment plans with them collaboratively (Welch, & Polatjako, 2016). I would explain to them in detail why Facilitated Communication (FC) might fail to work. I would explain to them that FC is not an evidence-based therapy method, and it stopped being used in the mid-1990s. It is not backed by adequate research, and it has not been scientifically proven to help autistic children communicate or behave better. In fact, several studies have shown that it affects the child's development negatively. The American Psychology Association (APA) recommends that FC not be used in the treatment of autism
3 because it can worsen the condition. In dissuading the parents from using FC, there should always be a balance of guidance, empathy, and education. Barriers to an Effective Rapport between Parents and the BCBA There are several barriers to effective rapport between parents and the BCBA. One of the main challenges is that the parent will often be a layperson who lacks knowledge on the best treatment despite having the best intentions for their child (Fong et al., 2017). Therefore, it might be challenging to get them to accept training that would help them understand the reason behind the treatment. Without adequate training, the parent will be unable to liaise with the therapist to develop a strategy to help the child. The second barrier to cooperation between parents and the BCBA is their judgment of the treatment effectiveness; this is commonly referred to as treatment acceptability. When the parent views the treatment plan as appropriate and acceptable, they are more likely to collaborate with the BCBA and accept their treatment plan. For instance, in this case, Kaitie’s parents feel that Facilitated Communication would be a more suitable treatment plan compared to the suggested home Program plan. Thirdly, parents of children living with psychological problems often have greater financial responsibilities because of the costs associated with providing proper care. They may be too stressed and fatigued to get fully involved in a parent training program from being busy working to meet their child's needs. The parent's education level is also a major deterrent to their ability to collaborate with the BCBA. Parents with a low education level may be more challenging to work, especially when they cannot understand the concepts behind certain training strategies. They may also believe strongly in practices that are not evidence-based, making it difficult for the therapist to implement scientifically-based practices. Strategies to Use as a Means to Establish a Therapeutic Relationship
4 Parental involvement in the child’s ABA therapy has been proven to be effective for children with autism. To promote the child's growth and development, it is crucial for the therapist to develop a collaborative relationship with the child's caregivers. The key step to establishing a therapeutic relationship with the child’s parents is to provide clear and succinct information on each of the approaches that will be used for treatment (Roane et al., 2016). When providing home therapy as a BCBA, building a positive relationship with the child's parents and caregivers is key to whether the therapy will be successful. Failure to win the parents' trust and incorporate them into the therapeutic strategies will hinder the treatment plan's success. In their training, BCBA practitioners are taught to carry themselves in a businesslike manner and this may affect their ability to build a rapport with the child's caregivers. To avoid this, it is important for the practitioner to understand the parents, listen to them attentively, and use jargon-free language when talking to them. It is also crucial to talk to them without judging them. The practitioner should respect the client regardless of their differences in race, culture and values. The client-practitioner relationship can also be strengthened by showing appreciation for their efforts; this will contribute significantly towards encouraging their participation in the therapy. Additionally, the therapist should assure the family that the information shared with the therapist will be treated with utmost confidentiality and that they are committed to helping the child progress despite their psychological challenges. Parents need to know that the practitioner is committed to supporting the child. They can do this by constantly being available to the family, through allowing consultation via phone around the clock whenever an issue arises. Outline The Process That You Would Use to Establish Kaitie’s Verbal Behavior Program Language is an essential part of a child's development. It helps the child express themselves and interact with the people around them. A key diagnostic criteria for autism is a
5 deficit in communication and interaction. Autistic children often have insufficient verbal and nonverbal skills, thus requiring a comprehensive verbal behavior program. DSM-V categorizes the language deficit on a scale of level 1 to level 3; with level 3 being the most severe category (Shyman, 2016). To improve Kaitie’s communication skills, I will implement verbal behavior (VB) therapy. It is a therapy strategy that draws its teachings from B.F. Skinner, one of the leading founders of behavior theories (Roane, et al., 2016). VB Therapy teaches autistic children to develop their language skills by relating a word to its purpose. It helps the child learn that they can get their caregivers' attention by expressing themselves either verbally or non-verbally. VB teaches autistic children the reason behind using words and how to use them effectively when expressing themselves. This has proven to be a more effective method of developing the language skills of autistic children (Pipkin et al., 2013). To teach Kaitie how to use language, I will first teach them four word types. These are; mand, tact, intraverbal and echoic. Mand words are used to make a request. For instance, simply saying ‘water’ is sufficient to draw the caregiver’s attention to the fact that the child is thirsty. Tact words are used to exclaim and draw the attention of the caregiver. For instance, saying ‘bird’ when they see a bird. Intraverbal words are used to respond to a question. For instance when asked “what’s your name?" she should be able to say "Kaitie". Echoic words are, as the name suggests, echoes of a word. For instance, when “Table” is said while pointing at a table, the student will learn by repeating the same word, "Table". Echoic words are, therefore, useful in teaching the child how to speak. As the therapist, I will teach Kaitie to speak mostly by pointing at an object and repeating the word. For example, I can present a flower and say, "Flower" repeatedly until over time, they associate the word 'flower' with the object I showed them. This is
6 done with a variety of everyday objects until the child begins to understand the meanings of words. Including the Specific Assessment and Teaching Methods, Providing a Clear Rationale for Your Decisions Teaching the autistic child verbal behavior entails providing instructions in both verbal and non-verbal behavior. The first and most important lesson when teaching the autistic child to speak is to develop their verbal imitation skills. This is referred to as ‘echoing’ Without the skill of mimicking, speech development becomes a major challenge. Once the child develops their language skills sufficiently through echoing the words uttered to them, the next step is to incorporate other language skills; that is mand, tact and intraverbal verbal operants (Pipkin et al., 2013). For Verbal Behavior programs to be effective, they should be performed for around one to three hours a week. A more severe speech deficiency such as Kaitie’s would require more intensive therapy and more hours. Overview of the Assessment Instrument Verbal Behavior (VB) is a crucial tool for measuring verbal behavior and ensuring that the deficits are addressed. It helps autistic children develop behaviors that will increase their competencies and skills. When ABA interventions are performed early enough, it helps control the child's negative behaviors, making it easier for them to develop essential life skills. Kaitie will benefit significantly from the application of the strategy. VB-MAPP is an assessment method that comprises five components. These are; Transition Assessment, Task Analysis and Supporting Skills Tracking, Barriers Assessment, Milestone Assessment, and VB-MAPP Placement and IEP Goals (Pipkin et al., 2013). These components measure an autistic child’s progress and areas for improvement in several aspects such as language development,
7 communication, and social skills, thus providing the ABA specialist with a guide on the areas to target during ABA therapy. In addition to establishing their level of social skills and language, it also helps in understanding the child’s learning style in order to develop a curriculum that is best-suited to their learning. The VB-MAPP, therefore, serves three main purposes; firstly, to assess the child’s level of development; secondly, to develop a curriculum that facilitates the child’s learning and development; and thirdly, to track the child’s progress in skill-acquisition in the course of learning. Once the VB-MAPP is administered, the ABA specialist and the child’s gaps are identified, will be able to design a suitable treatment plan. Hypothetical Results Related to the Existing and Target Verbal Operants in Kaitie’s Case For children with autism, language forms the most fundamental aspect of learning. With continuous and deliberate training, Kaitie will be able to focus on the instructor and react appropriately to instructions such as “sit down” or “stand up” (Shyman, 2016). She will also learn to imitate the instructor’s responses. With adequate training, Kaitie should be able to utter a few words when identifying something she sees or making a request. For instance, she can say, “Cookie”, when requesting a snack or "Plane,” when she sees an airplane. Kaitie will also learn to point at objects that are mentioned to her. For example, when the instructor says “flower”, she will point at the flower. However, this will require intense therapy over a longer period of time. Setting Up a Treatment Program using Discrete Trial Training Discrete Trial Training is a treatment plan that is commonly used in the treatment of autism (Roane et al., 2016). It involves breaking down skills to their most basic components to teach children in the simplest gradual manner possible. It is based on the premise that a child can acquire any skill as long as it is broken into small measurable steps. The autistic child is
8 motivated to learn by getting a reward for their efforts and accomplishments during the training. When successfully implemented, it can be used to teach autistic children many new skills. These skills include speech, sign language, following instructions, and writing. I would set up a training program using DTT by creating a training syllabus that seeks to achieve specific goals. In each period, I will teach a few specific skills, using reinforcers to ensure that I encourage positive behavior. For example, when teaching the child numbers, I will begin by teaching them to identify and perhaps enunciate number 1. When they are able to do so, I will reward them with a toy or candy, or even appreciation, and then move to the next number. I will do this until they learn as many numbers as possible. DTT helps autistic children understand through repeating the same concept severally. The steps and expected outcomes of each trial are well-defined and scripted. The outcomes are also recorded to assess the child’s progress at each attempt. A discrete trial is divided into six steps. These are; antecedent, prompt, response, the consequence for a correct answer, the consequence for an incorrect answer and inter-trial interval. DTT is effective in facilitating errorless learning because each step is well-defined and clearly scripted. DTT may be one of the most effective teaching techniques in Kaitie's therapy, for instance, in the process of teaching colors and numbers. In teaching the differences between colors blue and yellow, the teacher will hold out two cards, one is blue, the other yellow, and show Kaitie the blue one, saying, "blue… this is color blue". She will hold out the yellow one and say, "yellow… this is color yellow." A few minutes later, she will ask Kaitie to identify the blue sign, followed by the yellow sign. If Kaitie answers correctly, she will offer a reward such as a snack, and if she answers wrongly, she will repeat the lesson. The antecedent is the statement or question that necessitates a response; for instance, telling Kaitie to point at color
9 blue. The prompt is the teaching aid that the therapist uses to help the child learn, such as the blue card and the yellow card. The reinforcement is the reward given when the child answers correctly, it could be a snack or applause and affirmation. It is therefore, the consequence for a correct response. The correction procedure is the consequence of an incorrect answer. The teacher should correct the child immediately, calmly and firmly, by stating the correct answer. The correction procedure should be followed by another trial procedure to establish whether the child has understood the lesson. DTT is a data-intensive procedure because it involves collecting the data for each trial. When using DTT, it is essential to have data sheets that are specifically designed for the skill being taught; thus, the progress and outcomes of each training will be outlined on the sheets. The materials used to deliver the training include; notebooks, pens and markers, instructional materials, pictures and cards, tangible reinforcers, and learning toys. When the child provides the correct answer, the teacher will give them the reinforcer. Likewise, corrective measures should be implemented when the child answers wrongly. Providing effective management and supervision to the RBTs who will be facilitating the DTT program The DTT program will be executed through RBTs, and as the BCBA, it is my duty to ensure that they are well-supervised. The success of the program relies heavily on my ability to create an environment where the RBTs perform their duties professionally and in the best interests of the child. The supervision of RBTs entails selecting individuals who are competent for the role, setting clear goals, ensuring that they perform their duties as required, and correcting any performance-related issues that may arise promptly. As the BCBA, it is also my duty to keep the child motivated by providing diverse opportunities for them to learn and grow and reward
10 them appropriately. I will supervise the RBTs in accordance with the Compliance Code for Behavior analysts, which outlines in detail how the BCBA is supposed to approach their supervisory duties (Roane et al., 2016). The Code provides the ethical behavior that should be practiced by both the BCBA and the RBTs in the process of providing ABA training to the child. As their supervisor, I will outline the tasks that they need to perform daily, weekly and monthly. I will also set the expected outcome of their engagement with the child. I will monitor the keenly to ensure that they perform their duties as outlined, making corrections where necessary and providing positive reinforcement in order to encourage good habits. Maintaining and Generalizing Kaitie’s Behavior as Part of the Parent-Training Program Parents are the child’s primary caregivers and their participation in the intervention process is of utmost importance. The success of the ABA program relies significantly on the effectiveness of the collaboration between the BCBA and the child’s parents (Behavior Analyst Certification Board, 2014). To facilitate the success of the ABA intervention, I will work together with Kaitie’s parents to develop the therapeutic process instead of simply dictating one to them. When the parents are involved in the process, they tend to become more cooperative and compliant. Integrating Kaitie’s parents into the therapeutic process would entail sharing information with them openly, respecting their opinions, and allowing for negotiation and compromise where necessary. Both the parents and the BCBA have a common goal of improving the child’s skills (Vollmeretal, 2013). Providing treatment to Kaitie while incorporating her parents and considering their daily routines helps to generalize and maintain the skills learned.
11 Choose a naturalistic approach in which parents can be taught to implement procedures that will generalize Kaitie’s language skills into the natural home and community environments Using naturalistic approaches in parent-training is the process through which the BCAB identifies the most effective strategies for intervention, instructs the parents, RBTs and other intervention team members on how to apply them, creates an environment that facilitates the achievement of the desired behavior and which in turn helps the child with ASD develop in their communication and social skills. Kaitie is mostly non-verbal, therefore, the best approach to use under this strategy is the natural Language Paradigm. It will involve sitting face-to-face with the child and offering them a choice of three activities or toys to choose from. The therapist will then say the words that are related to the item that the child selected slowly and repetitively as the child plays with them. The child plays with the item for a while and then it is removed. The therapist will then ask the child to say the word they learned, for instance, “ball”. When they repeat the word, the item will be returned to them to continue playing (Welch, & Polatjako, 2016). This reward process motivates the child to continually learn more words. Pivotal Response Training is another therapeutic approach that can be taught to parents to facilitate the autistic child’s development. It involves inculcating into the child the motivation to learn, willingness to communicate and ability to monitor their behavior. In PRT, the lesson is mostly centered around play, and the child is allowed to lead the session. They choose the game they want to play, and what they want to talk about or learn. PRT is an effective therapy in parent training because it can be easily integrated into the child’s day to day life. Performance Management
12 In ABA, parents and caregivers play a fundamental role in implementation of the treatment plan. It is therefore crucial to gauge how well the parents, caregivers and family have been able to learn to provide training to the child. Performance management is a three-step process that involves measuring performance, providing feedback and encouraging positive behavior from the parties involved. Performance management will help the BCBA determine the progress of the intervention methods applied, and either continue applying them or adjust them to better suit the child (Trump et al., 2020) The facets I would apply, therefore, are performance measurement, feedback and reinforcement. Support staff and parents should dispense reinforcement and consequences appropriately, consistently and at the right time. This will help the child learn that correct behavior attracts a reward. In assessing the performance of the parents and caregivers, two of the things to look out for are their consistency and accuracy in applying the trainings. Children learn best when the training is repeated and is applied in the same manner throughout. It is also important for the parents and caregivers to provide feedback on their progress. This helps in making corrections where necessary. Part 3: Evaluating the Program I would evaluate the program by its ability to achieve the desired goals. For instance, in this case, the goal is to increase Kaitie’s verbal and social skills. Therefore, I will measure the effectiveness of the program by assessing the improvements the child has made in different facets of their verbal and social development. Program evaluation will also involve appraising the RBTs and caregivers to determine whether they have performed their roles effectively. If my assessment shows that the desired objectives are not being achieved, I will first determine the reason for this failure and address it in the appropriate way. For instance, if the parents are uncooperative or failing to implement the strategies in their interaction with the child, I will
13 reiterate to them the importance of cooperating with the professionals to develop the child’s skills. In case it is a failure by the RBTs, I will ensure that they have the right skills by retraining them. It might also be important to alter the strategy to one that is more effective. When the goals are achieved, it is crucial to recognize the efforts of the people who have made the achievement possible. This will reinforce the positive behaviors. Ethical Considerations Acting ethically is one of the fundamental bases of Applied Behavior analysis. The BACB Code provides rules and regulations that maintain professional standards in the practice of behavior analysis. The core ethical values are; to act responsibly, be truthful and just, to treat the child and others with dignity and to pursue excellence at all times. The practitioners must at all times act in the child’s best interests irrespective of the environment, pressures, personal preferences or history (Shyman, 2016). To comply with the legal aspect of the Code of Ethics, the RBTs and BCBA must be formally trained and certified. This ensures that they have the capacity to make the right evaluation, provide the right treatment in a conducive therapeutic environment. Acting ethically also involved maintaining client-patient confidentiality and avoiding situations that would cause a conflict of interest. Cultural competence is also a crucial aspect of the BACB Code of Ethics. The practitioners must, at all times, demonstrate cultural sensitivity (Weiss, PhD., 2019). Additionally, they must act in the best interests of the child regardless of the social background. The BACB Professional and Ethical Compliance Code (2014) should guide the professionals at all ties to ensure that they adhere to the guidelines.
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15 Roane, H., Fisher, W., & Carr, J. (2016).Applied Behavior Analysis As Treatment For Autism Spectrum Disorder. The Journal Of Paediatrics, 175, 27-32. Https://Doi.Org/10.1016/J.Jpeds.2016.04.023 Robinson, L., &Hammitt, J. (2011).Behavioral Economics and Regulatory Analysis. Risk Analysis, 31(9), 1408-1422. DOI: 10.1111/j.1539-6924.2011.01661.x Shyman, E. (2016). The Reinforcement of Ableism: Normality, The Medical Model Of Disability, And Humanism In Applied Behavior Analysis And ASD. IntellectuaAnd Developmental Disabilities, 54(5), 366-376. Https://Doi.Org/10.1352/1934-955654.5.366 Trump, C. E., Ayres, K. M., Quinland, K. K., & ZABA la, K. A. (2020). Differential Reinforcement Without Extinction: A Review Of The Literature. Behavior Analysis: Research And Practice, 20(2), 94–107. Https://Doi.Org/10.1037/Bar0000169 Vollmer, T., Roane, H., Ringdahl, J., & Marcus, B. (2013). Evaluating Treatment Challenges With Differential Reinforcement Of Alternative Behavior. Journal Of Applied Behavior Analysis, 32(1). Https://Doi.Org/10.1901/JABA .1999.32-9 Welch, C., & Polatjako, H. (2016). Applied Behavior Analysis, Autism, And Occupational Therapy: A Search For Understanding. The American Journal Of Occupational Therapy, 70. Https://Doi.Org/10.5014/Ajot.2016.018689 Weiss, PhD., M. (2019). The Ethical Imperative to Ensure Cultural Competence and Sensitivity among Behavior Analysts. Behavior.org. Retrieved 18 January 2021, from https://behavior.org/wp-content/uploads/2019/08/WeissETHICS2019.pdf.
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