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This article was contributed by Leica Anzaldo, Training Manager for the Autism Society of North Carolina.

Applied Behavior Analysis (ABA) has gotten a bad rap over the years, and up until a few years ago, I too had some misconceptions. Common assumptions are that ABA:

• creates robotic results
• is very rigid and does not allow the child to play
• is a pre-packaged treatment
• is only for young children
• does not include any other treatments
• is done at a desk or section of the room, etc.

What ABA truly is, is the applied practice of behavioral principles in everyday settings and situations. The purpose of ABA is to 1. Increase desirable targeted behaviors and 2. Decrease undesirable targeted behaviors. For children and adults with autism, ABA has been used to help develop many skills in areas including communication, social, self-help, self-regulation, and play. These principles can also help decrease maladaptive behaviors such as aggression, self-stimulatory behaviors, and self-injury. ABA is evidence-based, is appropriate for lifelong interventions, and is not only for the treatment of undesirable or maladaptive behaviors.

The Clinical and Training Department of the Autism Society of North Carolina (ASNC) provides ABA interventions to participants in several ways. The department is receiving a growing number of referrals for Specialized Consultative Service cases throughout the state. Board Certified Behavior Analysts (BCBA) and/or Licensed Psychological Associates (LPA) develop behavior plans based on the history of the individual, assessments, data, and most importantly, observation. The plan is then reviewed by a Licensed Psychologist and ASNC’s Human Rights Committee. The BCBA or LPA then coaches the family and/or skill-building staff on the strategies defined in the plan, collects and analyses data (such as ABC data, frequency measures, etc.), and makes recommendations.

This service is available for all ages and abilities who receive services through the Innovations Waiver. Some funds at the local level also may support this service, and this service is available through private-pay services and includes implementation of treatment options for young children. This typically involves tutor staff who are trained on the evidence-based treatment, coached on the child-specific elements of the plan, and supervised regularly by a BCBA. These services are typically only available via private-pay, because ABA and autism insurance coverage is not available in North Carolina with few exceptions. Some younger children do qualify for Medicaid Waiver services or locally funded services (through the MCO). Also, some insurance plans – if they originate in a state with autism or ABA coverage or include an autism rider – will cover ABA services. For more information on your specific insurance carrier, please contact the carrier’s claim or care coordinator directly.

Finding a Good Board Certified Behavior Analyst

So how do you select a good BCBA, or paraprofessional who will implement the goals? First, consider whether the person is a good “fit” with your family. Developing relationships among the BCBA, paraprofessional, and individual receiving intervention is critical. I will often encourage families to allow myself and/or the paraprofessional to spend several sessions just getting to know the child or adult before beginning any interventions. If a BCBA shows up at your door with a “prepackaged” treatment, I would be wary. Each child and adult is unique, and therefore their intervention package should be unique to them. If your child and the BCBA don’t “click” after several sessions, or the BCBA or paraprofessional’s arrival immediately induces unmanageable stress and anxiety in your child, this is a signal that perhaps you should ask whether other staff are available.

Creating an ABA Program

The BCBA should always include you, the parents or caregiver, in treatment. A parent/caregiver is critical to the success of each program. They are the ones who know the most about the person and will be responsible for prompting and reinforcing ongoing, everyday activities in promotion of generalization and collecting data on a daily basis. The ABA program should be written so that it can be incorporated all day, every day. ABA should never take place in only one location, with one person at a certain time of day.

Intervention programs should include the following:

• antecedent manipulation (including the use of visuals in many situations) that cues a positive behavioral response
• an emphasis on increasing functional alternative/replacement behaviors rather than only decreasing problem behaviors
• programming that includes multiple settings/environments
• data-driven decision making
• preference assessment and capitalization of motivating tactics, a plan for reinforcement, plan for prompting and prompt fading, communication strategies including in many cases promotion of social bids including joint attention.

I recommend that several assessments be implemented before beginning any ABA program. The assessments are not mandatory, but they provide a baseline from which to build your program.

• a diagnostic assessment, using an autism-specific diagnostic tool such as the Autism Diagnostic Observation Schedule (ADOS)
• a developmental assessment to measure cognition, communication, motor, adaptive, and social skills
• a criterion assessment to measure specific areas that may be targeted through intervention such as: Functional Behavior Assessment, Early Start Denver Model Assessment (ESDM), Assessment of Basic Language and Learning Skills (ABLLS), the Verbal Behavior Milestones Assessment and Placement Program (VB-MAPP), and assessment of social skills, joint attention or play

Don’t be turned off if you experience variations in treatment. Many skilled clinicians vary treatment based on their expertise and the individual’s needs and skills. For example, I often employ elements of Pivotal Response Treatment, Early Start Denver, Structured Teaching, and RDI, many of which are based on Applied Behavior Analysis. The effectiveness of a program should be obvious through the data summaries you receive and the observable improvements in your loved one. Keep in mind, though, that change takes time. The National Professional Standards Project recommends at least 25 hours a week of therapy. This may seem very unreasonable for many. Keep in mind that this is a recommendation, not a mandate, and you should do what is comfortable for your family. Also keep in mind that those hours can and should include your implementation of goals on a daily basis.

If you are interested in hearing more about consultation and intervention programs available through the Autism Society of North Carolina, please contact the Clinical and Training Department at 919-865-5059.

Leica Anzaldo can be contacted at 704-894-9678, ext. 1603, or lanzaldo@autismsociety-nc.org.

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