Amidst increasing alternative convincing treatments readily available and advertised, there is still no ‘magic pill’ for the treatment of autism. The results we see in children with autism is still through the combined effort and hard work of the child with autism, parents, their family (this sometimes includes siblings, grandparents & helpers) and a well supervised and trained Applied Behavioural Analysis (ABA) team.
The basic principles of ABA have been outlined here. A brief summary is that whatever behavior we reward (whether through giving attention, social reinforcement or external motivation) will increase. Secondly, good quality ABA programmes are able to break skills down effectively, pair the skill with reinforcement and provide sufficient practice in order to help that skill become established.
Additionally, we at EAP have listed down 8 key rationale reasons for why ABA remains the most effective treatment for autism to date:
- Individualised Programmes
Firstly, it is important to note that autism is a spectrum disorder. This means that there is a broad range of children with very minimal symptoms of autism to extremely severe symptoms of autism. Therefore, the symptoms of autism as listed in the DSM-5 all manifest differently and with variation. Over the last 10 years, we at EAP have not seen any two children alike amongst over 300 children from 30 different countries. Every single child has demonstrated different strengths and challenges.
This means that a child diagnosed with autism requires an individualized curriculum, a programme that is personalized by an experienced ABA Supervisor who has been trained in the craft of ABA programming for a child on any range of the autism spectrum. Additionally, the programming has to be age-appropriate.
At EAP, we train our Supervisors in-house as these selected individuals have been through our EAP therapist training programme and we have supervised their clinical work for 2 years before they are trained intensively for over 6 months. The support does not end there as the quality of their work is monitored through weekly meetings with an EAP Senior Supervisor, the full EAP clinical team as well as our parent company in Wisconsin, WEAP.
- One-to-one teaching
As mentioned, if children with autism can be so different from each other and require individualized programmes, this will be difficult to be executed in a group setting. Even with the most qualified and trained teacher, he or she is only one person and it will not be possible to teach children with autism effectively in a group in the initial stages of treatment.
This means that at the beginning of treatment, when a child with autism has limited foundational skills such as cooperation, imitation, attention, as well as effective communication and social engagement, the child requires a therapist’s full focus and attention to maximize their potential.
At EAP, all our children have individualized programmes and start with one-to-one teaching. This remains to be the most effective strategy as our therapists are able to target many skills in each hour of teaching, which is extremely important to a child with autism’s chance to catch up. As the child shows progress and increased group readiness skills, we gradually build up peer interaction, starting with one child then two children then transition to a small group setting and then eventually to school with the support of an EAP trained shadow/Personal Learning Assistant.
- Intensive hours (35 hours a week)
There are 24 hours a day, 168 hours a week. If a child sleeps 12 hours a day, that leaves us with a remainder of 12 hours of free time a day or 84 hours a week. That is a lot of free time. It is very important that we understand that unlike typically developing children who are learning from their environment all the time through inbuilt skills of attention, observation and imitation, children on the autism spectrum may be in their own world or repetitively participating in activities that are not meaningful – also known as ‘stimming’.
The bottom line is that whatever behavior we spend a lot of time practicing, that behavior becomes an established behavior. In the example of a child with autism, he may spend the most of his time practicing stimming behaviours which will strengthen that behavior. Additionally, he may not demonstrate eye contact and not speak which is also a skill he is practicing – to not engage with people and to not speak.
Therefore, in order to curb inappropriate behavior and to increase new skills, it is recommended that a child with autism in the initial stages of treatment, receive between 30-35 hours of therapy a week. At EAP, during these hours, a child with autism will have a team of therapists rotating to work with him or her and the therapist will keep the child engaged with meaningful activities and teaching new skills as quickly as possible to achieve the child’s best potential. Research shows that almost 50% of children who receive intensive ABA treatment are able to catch up to their peers and achieve average IQ levels as well as transition to typical school.
- Early Intervention
We are all aware of children’s ability to learn so much quicker when they are younger, which is why we want our children to learn a musical instrument, dance, sports or even another language because they have the ability to absorb like a sponge.
When it comes to children with autism, there are a number of reasons why they should receive intensive ABA early.
Firstly, there is a period of rapid development in a child’s brain from birth, which means they have the most potential to learn as quickly as possible at that age.
Secondly, the brain is more malleable at that age and therefore, inappropriate behaviours are easier to be redirected to appropriate skills.
Lastly, there are less skills to catch up. For example, a 3-year-old who is demonstrating the skills of a 1-year-old, technically only has a 2-year delay, whereas if that same 3 year old did not receive early intensive ABA and continued on with life, at 13 years old chronologically, he may still be functioning at a 1 or 2-year-old level. This now is a 12-year delay.
At EAP, we have started with children as young as 18 months and at the same time, with individuals as old as 18 years old. What is most important is the individualization of the programme, as well as the experience and supervision of the team to maximize each individual’s learning.
- Start with Success
Children with autism have quite a few challenges and need to work extra hard in order to make progress. It can be very frustrating for them to be put in teaching environments that are demanding and with expectations they are unable to meet. This often results in an increase in behaviours like self-stimulatory behaviors due to anxiety, frustration and task avoidance as well as aggressive behaviours.
Therefore we believe that complex skills need to be broken down to smaller components parts to make learning easier. Each child starts at a successful level which provides a positive association to learning. The more successful the child is, the more willing the child is to learn. We also do not underestimate the power of confidence and prioritise building confidence in each of our children.
For example, if our long-term goal is for a child to be able to sit at the table in school and learn from the teacher, we need to develop a programme to build attention based on the individual child. We may need to start with 1-2 minutes at the table and then gradually build it up to 5-10 minutes of successful learning at the table. Do note that this needs to be age-appropriate and this is not recommended for very young children.
- Positive Approach of Teaching
As mentioned in the previous point, we really want our kids to feel successful and have a positive experience of learning. This includes good relationships with their therapists and all our team at EAP are trained to build rapport with each child. This needs to be adapted accordingly to each different child.
ABA uses positive reinforcement to increase positive behaviors and social interaction, and decrease inappropriate behaviors. Therefore we need to be able to identify what is motivating to each individual child and initially pair their learning with external motivation with the intention for the child to become intrinsically motivated. These reinforcements can range from food rewards (in the initial stages) to tangible items (e.g. toys, stickers, games), or even interactive activities and social praise.
As many of our kids progress, their reinforcement becomes more naturalized such as choosing their next play activity, or earning points to have a special weekend outing and some of our kids are happy just to earn a certificate or a badge.
What is essential is that we pair learning with fun, reinforcement and motivation. If we are not having fun ourselves, it is unlikely that they are having fun.
It is also important to note that no adverse teaching of any sort is tolerated at EAP. We do not believe in fear-based teaching as it is not internally motivating to the child and many children with autism may imitate that aggressive behavior to other children.
- Comprehensive Programme
It is vital that a good quality ABA programme is comprehensive and covers all areas of a child’s development. Each of the children in our programme have ongoing targets that are chosen based on priority and age appropriateness in the following areas:
- Early Learner Skills (cooperation, imitation & attention)
- Communication & Language
- Play Skills (leisure skills for older individuals)
- Social Skills
- Daily Living Skills (personal, domestic & community)
- Pre-Academic & Cognitive Skills
- Generalisation of all skills learned
While a multidisciplinary approach may be advised, when there is a lack of national standards of practice or good governance, this can become a case of ‘too many cooks spoil the soup’ or a ‘bystander effect’ with a lack of focus and direction to lead the child’s overall development with a clear strategic direction.
- Multiple Levels of Supervision
As each child on the spectrum is so different, the individualizing of each child’s ABA programme is very important. Furthermore, children with autism have a window that is dependent on their developmental age to learn rapidly and their learning time needs to be maximized to their best potential.
It is therefore essential that a child with autism receives the best quality treatment and this can only be achieved through thorough training and supervision.
Each child in the EAP programme has a complete ABA team consisting of 2-3 therapists, a Supervisor, a Senior Supervisor as well as the WEAP (Wisconsin Early Autism Project) Senior Consultant. Every level of the EAP team (Therapist, Supervisors, Senior Supervisors) receives intensive initial training for their roles and then continuous regular supervision and ongoing training.
Team meetings are held fortnightly with the child, family, team of therapists and Supervisor. This is a compulsory meeting and the quality of the child’s programme is determined by this meeting as the child’s progress is reviewed, changes are made and new targets are introduced. Everyone demonstrates working with the child in order to ensure consistency and continuity. Fortnightly overlaps are also conducted with each therapist to ensure quality therapy.
On a bimonthly basis, the EAP Senior Supervisor comes in to these Team Meetings in order to provide further supervision and direction. Additionally, the Senior Supervisor meets with each EAP Supervisor individually on a weekly basis to discuss their caseload as well as a group clinic team on a fortnightly basis.
Twice a year, our parent company WEAP sends a Senior Consultant, who is a doctorate level clinician, to conduct Progress Reviews with every single child and family individually.
EAP also has compulsory monthly clinics for all staff and regular Saturday trainings, workshops and conferences as well.
We hope these points have been helpful to explain fundamentally why ABA works. It is also important to note that ABA is extremely effective and successful in the treatment of children with autism when implemented correctly and following certain standards of practice to ensure quality.
We at EAP Malaysia follow the standards of practice set by our parent company Wisconsin Early Autism Project, as there are no national standards of practice for ABA in Malaysia. We are deeply concerned with the many stories we hear of poor practice, usually due to the lack of training, supervision and governance.
If you have find that you have enrolled in an ABA programme and have not seen progress with your child with autism, do contact us today for a review appointment and we should be able to find the solutions to improving your ABA programme. You can also download a FREE RESOURCE we have on the Applied Behavioural Analysis (ABA)!