Applied behavior analysis (ABA) interventions have been proven to be extremely effective for children with autism spectrum disorder (ASD), increasing their skills and reducing problem behavior (National Autism Center, 2015). There are a variety of ways ABA can be provided, but the way it is often delivered, through intensive 1:1 therapy, has come to be viewed as the primary, if not only, option. This article will describe how ABA can be used within typical family routines to improve quality of life for children and families.
Issues with Delivering Intervention
Intensive 1:1 ABA therapy has advantages in that behavior change can occur quickly under controlled situations. It can, however, have drawbacks for some children and families. First, the skills developed can sometimes seem rote or not fit the circumstances. For example, a child may learn specific words or problem-solving strategies that other children do not typically use, setting him/her apart from same-aged peers. Second, some children resist participating in repeated learning trials, resulting in an increase in their challenging behavior. Third, the impact of 1:1 therapy may not “generalize” across time, people, and/or circumstances. A child may perform well for his/her therapist only. Finally, when poorly planned, ABA therapy can interfere with valued family routines. Parents may find themselves rearranging daily activities to accommodate professional schedules. For these reasons, ABA therapy can increase stress rather than make family lives better.
It is important that parents understand that ABA strategies can be embedded in typical family routines. This approach can improve day-to-day interactions and activities, thereby improving family quality of life. Current early intervention and family support programs emphasize aligning goals with family values and needs, empowering parents and other typical caregivers, and focusing on strategies that can be easily maintained in natural settings (Division for Early Childhood, 2017). Recent research in routine-based ABA, also known as “positive behavior support” (Bailey & Blair, 2015; Fettig & Barton, 2013; Lucyshyn et al., 2015; Sears, Blair, Iovannone, & Crosland, 2013), suggest it offers a great alternative or supplement to direct intensive treatment.
Process of Routine-Based Intervention
The following sections of this article will describe how ABA can be used within family routines, providing an example during sibling play. The process includes identifying goals, assessing patterns, designing strategies, using the plan, and monitoring outcomes.
Identifying Goals. The process begins with identifying child and family goals, considering ways in which the child’s quality of life needs to be enhanced and focusing in on the routines the family most want to improve. A family might choose getting ready for the day, hygiene, meals, playing with siblings or peers, or participant in extracurricular activities, for example. The specific goals of intervention, including skills to develop and behaviors to decrease, are selected based on the routines and goals desired.
Example: More than anything, Savannah would like Tristan and Emily to be able to play together nicely so she could have a little time to herself and the children could learn to enjoy one another’s company. Unfortunately, play times are often shortened by Tristan’s tantrums. Savannah’s goals are for her children to be able to share their toys and take turns playing games for at least 45 minutes, without Tristan screaming, throwing items, or striking his sister.
Assessing Patterns. Once clear on the goals, an assessment is conducted to determine patterns that may be affecting the child’s behavior within the routine. Specifically, we would want to know what happens before the child’s behavior (e.g., who is present, when and where it occurs, what is expected, what is happening), both when he is successful and when his behavior during the routine is particularly challenging. We would also want to know what the child gets or avoids through his behavior such as attention, items, activities, or breaks from the situation. This information is collected with the family through interviews and observations and is summarized to guide intervention.
Example: Paying close attention to play time, Tristan’s behavior specialist helped Savannah sort out what circumstances were contributing to his behavior. They found that Tristan played cooperatively when the rules of games were clear, and he had more personal space. He had the most difficulty with new toys and games – and when he was tired or hungry. Savannah would typically stay away when the children were getting along. When Tristan screamed or got physical, she would counsel him about his behavior and often asked Emily to let Tristan have the toys to make peace.
Designing Strategies. Using the patterns from the assessment, we can develop strategies that (a) work given the patterns affecting the child’s behavior and (b) fit with the family lifestyle. Strategies fall into three categories and the specific strategies chosen are tied to the patterns. Proactive strategies involve preventing problem behavior and prompting positive behavior by rearranging environments or establishing expectations. Teaching strategies focus on building skills a child can use to replace their challenging behavior and participate more successfully in the routine. And management strategies are focused on consequences, specifically providing reinforcement for positive behavior and withholding it for problem behavior.
Example: Based on the patterns, the following strategies were developed for Tristan and the family.
|Proactive Strategies||Teaching Skills||Managing Consequences|
|· Organize play areas to provide more space, including an area for breaks from the action
· Create a list of playtime rules, using pictures to illustrate
· Introduce new games by going over the steps and rules
· Create plans for sharing toys (who gets what, for how long)
· Provide snacks/meals before play and schedule playtimes when Tristan is well-rested
|· Teach Tristan to ask for what he wants using pictures or pointing to items
· Teach Tristan to share the toys, taking turns or setting a timer
· Teach children to get a parent when frustrated (with Tristan signing “help”)
· Teach Emily to prompt Tristan to use his words
|· Join in when the children are playing cooperatively, praising positive behavior
· Change toys and games after every 10 minutes of cooperative play to maintain novelty
· Remove toys if children are fighting over them
· Limit conversation following problem behavior, while still keeping children safe
Using the Plan. Once the strategies have been developed, it is important to plan carefully how they will be put in place and maintained. If professionals are involved, they should serve as coaches, rather than implementing the interventions themselves when possible so that they are building the capacity of the family. If children’s skills cannot be established without additional practice, it may be helpful to conduct additional “trials” (e.g., having Tristan practice using picture cues to request items), while continuing to support the routines. Really the emphasis is on teaching – arranging the environment, prompting skills, and rewarding children for increasing success and independence.
Example: To put the playtime plan in place, Tristan’s behavior specialist helped Savannah reorganize the family room and landing between the children’s bedrooms. They put the games into plastic bins so that all the pieces were together and created a “time-out box” for toys that caused arguments. They bought a ‘sharing timer’ and created rules with pictures of the children playing cooperatively. They made picture cards for Tristan’s favorite activities and toys. They selected five of the children’s favorite activities and reviewed and practiced their steps and rules with the children. They reviewed the plan with Grandma, who watches the children regularly. The behavior specialist modeled some of the strategies at first, but then quickly removed herself and simply provided support and feedback.
Monitoring Progress. It is important to objectively track whether children’s behavior is improving – making sure that skills are increasing and problem behavior is decreasing, as well as whether overall goals are being met. With objective information, families are more prepared to tweak aspects of the plan when it is not working – and celebrate successes. Monitoring by behavior specialists and other professionals can be pretty complex (e.g., recording every time a behavior occurs), but monitoring progress may be simplified in everyday family life by using something like a rating scale.
Example: To monitor the plan and outcomes, Savannah decided to record how long her children were able to play cooperatively (without screaming or aggression) each day. She noted the times on the family calendar. She also rated how well Tristan adhered to each of the playtime rules each day using smiley (good), straight (OK), and sad (poor) faces using the following chart. She reviewed these data with the behavior specialist and other family members every week.
Initially, Tristan was only able to play nicely with Emily for about 5-10 minutes. By using the plan, this time was gradually extended to almost an hour, with most rules being followed consistently.
The ultimate goal of any ABA program is to improve not only behavior but also the lives of children and their families. By focusing on valued routines and designing strategies that fit in the context of family lives, we can achieve this goal.
This article was featured in Issue 72 – Sensory Solutions For Life