The Use of Intensive Behavioural Intervention for Children With Autism Volume 14, Number 2, 2008 Abstract Autism is a pervasive developmental disorder with prevalence rates increasing yearly. Autism is Authors characterized by impaired social interaction, specific Christina de Rivera language abnormalities, behavioural stereotypes, and a range of cognitive deficits. The presence of CanCog Technologies, Inc. symptoms and the severity impairments vary from Toronto, Ontario individual to individual with deficits ranging from non-verbal and severe intellectual disabilities, to high-functioning. Currently, there is no cure for autism. However, intensive behavioural intervention (IBI) is gaining worldwide popularity as the treatment of choice. Intensive behavioural interventions have roots in applied behavioural analysis. The efficacies of the methodologies that have been used worldwide have varied. This paper compares the original IBI program developed by Lovaas with the current program used by the Toronto Partnership for Autism Services. Research is needed to determine what aspects of IBI are most effective for children with autism, which children benefit the most, if IBI is needed on a continued basis to maintain gains that are made, and if IBI programs are cost-effective for the government. Correspondence Christina de Rivera First described by Leo Kanner in 1943, autism christina.derivera@ was considered to be found in children who had a utoronto.ca serious inability to foster relationships with other people before 30 months of age. These children had Keywords abnormal language development and participated in stereotyped behaviours with an insistence on intensive behavioural sameness (Kanner, 1943). Today, it is considered intervention, one of the pervasive developmental disorders and autism, pervasive developmental diagnosis is usually made using the Diagnostic disorders, Statistical Manual IV-TR (American Psychiatric Lovaas method, Association [DSM-IV-TR], 2000) or World Health Toronto Partnership for Organization criteria (World Health Organization, Autism services 1994). (See also Fletcher, Loschen, Stavrakaki, & First, 2007a, 2007b). 2 DE RIVERA In the mid to late 1990s, the prevalence of of a behavioural response affects the autism was estimated to be approximately likelihood that the individual will produce 1 in every 1,000 children (Fombonne, 1999). the behaviour again. According to B. F. Since then, there have been numerous Skinner, behaviour modification “consists reports suggesting that the prevalence of changing the consequences of behaviour, is increasing (e.g., Bello, 2007; Coo et al., removing the consequences, which may 2007; Rutter, 2005; Wing & Potter, 2002). have caused trouble, or arranging new The process of “diagnostic substitution”— consequences for behaviour which has the switching of children with another lacked strength (Skinner, n.d.). According special education classification to autism— to this theory, the consequences of accounts for a substantial proportion of one’s behaviour directly influence the this increase (Coo et al., 2007). However, likelihood that the behaviour will occur the possibility has not been ruled out again (Skinner, 1999). That is, behaviour that increasing prevalence is the result frequency increases when it is rewarded, of environmental factors (e.g., Bello, 2007; and decreases when it is followed by Rutter, 2005). punishment. Current treatment methods for the There are seven elements that are contained autistic spectrum disorders include in every ABA program (Baer, Wolf, & Risley, the management of associated 1968). First, the program must be applicable. medical problems, pharmacologic and That is, behaviours that are being targeted nonpharmacologic intervention for must have functional significance. Second, challenging behaviours or coexisting the program must include behaviours that mental health conditions, and use of are observable so that performance can complementary and alternative medical be recorded. Third, the program must treatments (e.g., Myers & Johnson, 2007). involve analysis that contains data that The application of intensive behavioural shows that behavioural improvements are intervention (IBI) programs has received due to the therapy. Fourth, the techniques the most attention in the treatment domain. used must be clearly documented so that However, there is currently no cure for another person can easily replicate the autism and no gold standard for therapy. program. Fifth, the program must follow The main focus of this review article is established principles, such as those of to summarize behavioural interventions operant conditioning. Sixth, the program based on applied behavioural analysis should produce changes in behaviour that principles and also to summarize research are relevant to daily living, thus increasing findings about the efficacy of this particular the quality of life of the person. Last, type of behavioural therapy. In particular, changes in behaviour produced during the original program developed by Lovaas the therapy should generalize to other and the Toronto Partnership Autism situations and environments. Services (TPAS) program are discussed. Applied Behavioural Analysis and Applied Behavioural Analysis Autism Applied behavioural analysis (ABA) is In a talk given by Dr. McEachin and a scientific approach that attempts to summarized by Hultgren (1998), twelve change behaviour systematically using particular behavioural issues in autism the principles of operant conditioning. were outlined, and ways in which those Operant conditioning is a training or issues could be resolved using the learning process by which the consequence principles of ABA were proposed. JODD IBI FOR CHILDREN WITH AUTISM 3 1. Children with autism are often not highly Consequently, it is imperative that motivated. Thus, ABA should focus on lessons be as interesting as possible so making learning tasks interesting so that that the therapist is able to hold the the child will be motivated to learn the child’s attention. task. This means that if the child has 6. Sixth, children with autism have difficulty correctly learned the task, the positive understanding abstract concepts. It is consequence associated with learning essential that the therapist use simple, the task should be clear and sufficiently clear, and concise language so the child different from the negative consequence is able to follow the directions necessary of not having learned the task. In this to learn and perform the task. way, the child is able to see the cause 7. Children with autism have difficulty and effect relationship between correct learning by observation. This drives the learning of the task and its associated previous point about how children with positive consequence. According to autism need simple, clear, and concise the theories of operant conditioning, instruction about how to perform certain consequences normally have behavioural tasks. reinforcements associated with them (Skinner, 1999). 8. Children with autism have difficulty differentiating relevant stimuli from 2. Children with autism need tangible irrelevant stimuli. It is very important reinforcements. According to Dr. for the therapist to draw the attention McEachin, social reinforcements, such of the child to relevant stimuli so that as words of approval, are not usually he or she is able to make the correction sufficient to elicit the target behaviour. stimulus-response relationships. Making Instead, children with autism need connections between the stimulus, tangible reinforcements, such as edibles one’s response, and its consequence is or time to play with their toys. fundamental for effective behavioural 3. Children with autism have very short intervention based on ABA principles. attention spans. Thus, to ensure maximal 9. Children with autism often partake in effectiveness of behavioural treatment, behaviours, such as self-stimulation, that ABA breaks tasks down so that small can interfere with their learning. Thus, steps can be learned at a time. the first goal of the therapist is to stop 4. Children with autism are also easily the interfering behaviour so that he or distracted. Therefore, ABA therapy she can concentrate on teaching the task. initially takes place in a quiet environment This way, the child is able to devote 100% with few distractions to maximize of his or her attention into learning the learning potential. The eventual goal of task. the therapy, however, is to be able to 10. Children with autism learn better in generalize the behaviours learned during small groups. Because of this, most ABA ABA therapy to more natural settings, therapy is performed on a one on one such as play time or at school. Thus, basis. The ratio of children to therapist is as children become more successful in only increased once the child has shown performing a specific task, therapy may that he or she is able to learn in a one on move to more naturalistic environments. one setting. 5. Aside from learning difficulties due to 11. Children with autism do not use free attention span, children with autism time effectively. For this reason, ABA generally learn more slowly. Therefore, therapy is very structured, and to keep children with autism need a lot of the therapy interesting play skills are repetition to learn a particular task. incorporated into the schedule. V.14 N.2 4 DE RIVERA 12. Children with autism have sensory and/ child, preferably between the ages of 3½-5 or motor impairments. Thus, ABA therapy years. Due to