Journal of Intellectual Disability Research doi: 10.1111/j.1365-2788.2006.00940.

x
598
volume 51 part 8 pp 598–605 august 2007

Applied behaviour analysis: does intervention intensity

relate to family stressors and maternal well-being?
A. Schwichtenberg & J. Poehlmann
Waisman Center, University of Wisconsin, Madison,WI, USA

Abstract data collection, all families had been running a

home-based ABA programme for at least 6 months.
Background Interventions based on applied behav-
Results Single-sample t-tests and multiple regres-
iour analysis (ABA) are commonly recommended
sion analyses were used to test the proposed
for children with an autism spectrum disorder
hypotheses. Mothers of children participating in a
(ASD); however, few studies address how this inter-
home-based ABA programme reported more
vention model impacts families. The intense
depressive symptoms than mothers of children with
requirements that ABA programmes place on chil-
other developmental disabilities. Comparisons
dren and families are often cited as a critique of the
revealed comparable depressive symptoms between
programme, although little evidence is available to
the mothers of the present sample and those in
support this claim. Using Pearlin’s (1999) stress
other ASD samples. When considering weekly ABA
process model, this study assessed: (1) whether
intensity, mothers reported fewer depressive symp-
mothers of children participating in a home-based
toms when their child was older and when their
ABA programme reported elevated depressive
child participated in more ABA therapy hours. Con-
symptoms; and (2) whether ABA intensity related
versely, mothers who were more involved in their
to unmet family needs and maternal feelings of
child’s ABA programme reported more personal
depression, personal strain and mastery.
strain.
Method Forty-one mothers of children diagnosed
Conclusions The findings of this study supported
with an ASD participated in this study by complet-
the hypothesis that families participating in ABA
ing questionnaires about their child’s ASD behav-
experienced elevated depressive symptoms, much
iours, unmet family needs, and maternal feelings of
like any family raising a child with an ASD, suggest-
depression, personal strain and mastery. Addition-
ing a potential area for family-level intervention.
ally, mothers provided information about their
Additionally, ABA intensity related to maternal
child’s intervention programme and their own level
depression and personal strain, and therefore
of involvement in the programme. At the time of
deserves continued attention. Future studies should
attempt to replicate these findings with a larger and
Correspondence: Mrs A. J. Schwichtenberg, Waisman Center, Uni-
more representative sample and seek to identify
versity of Wisconsin-Madison, 1500 Highland Avenue, Room 544, mechanisms through which ABA intensity may
Madison, WI 537056, USA (e-mail: ajschwichten@wisc.edu). influence maternal and family well-being.

© 2007 The Authors. Journal Compilation © 2007 Blackwell Publishing Ltd

 Journal of Intellectual Disability Research
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A. Schwichtenberg & J. Poehlmann • ABA intensity and family outcomes
Keywords applied behaviour analysis, autism,
depression, family, intensity
Applied behaviour analysis (ABA) is a common
intervention model for children with an autism
spectrum disorder (ASD); however, few studies
address how this intervention model impacts fami-
lies. With the increase in ASD diagnoses (Chakra-
barti & Fombonne 2005), communities have seen
amplified needs for treatment and increased con-
cerns regarding intervention efficacy and intensity.
Understanding how intervention characteristics
such as intensity affect families is a crucial provision
of family support and informed intervention recom-
mendations. For the purposes of this study, ABA
was defined as an intervention approach that
follows the discrete trial format outlined by Lovaas
& Buch (1997) or Maurice (1996).
Using Pearlin’s (1999) stress process model, this
study assessed how ABA participation and intensity
related to family stressors and maternal feelings of
depression, personal strain and mastery. On the
basis of this model, stressors are divided into two
categories: primary and secondary. Primary stres-
sors are the original source of stress, whereas
secondary stressors refer to demands or strains
associated with the primary stressor. The influence
of these stressors is linked to family resources and
context. Pearlin (1999) describes outcomes as
indices of mental health. In this study, ASD behav-
iour presentation was conceptualized as a primary
stressor, unmet family needs as a secondary stres-
sor, maternal feelings of depression, personal strain
and mastery as mental health outcomes, and ABA
intervention intensity as a potential resource for
families (Fig. 1). Conceptualizing ABA intensity as
a resource stems from the broader literature base
wherein positive family outcomes have been associ-
ated with intervention models that incorporate
parental involvement (Baker et al. 1991; Koegel
et al. 1996).
It is well documented that mothers raising a child
with an ASD report more depressive symptoms
than mothers raising children with other develop-
mental disabilities (Olsson & Hwang 2002;
Abbeduto et al. 2004), although Eisenhower et al.
(2005) is an exception. However, most studies have
not considered maternal depressive symptoms
within the context of the child’s intervention
© 2007 The Authors. Journal Compilation © 2007 Blackwell Publishing Ltd
volume 51 part 8 august 2007
Primary Stressor Secondary Stressor Mental Health Outcomes
ASD Unmet Depression
Behaviour Family Strain
Presentation Needs Mastery
ABA
Intensity
Resource
Figure 1 Conceptualization of this study within Pearlin’s stress
process model. ABA, applied behaviour analysis; ASD, autism
spectrum disorder.
programme. In families following an ABA model,
parents are often encouraged to take on the roles of
teachers and therapists (Bailey et al. 1999). Initially,
it was predicted that these practices would increase
family stress. However, there is little empirical
evidence to support this claim. On the contrary,
Birnbrauer & Leach (1993) actually found signs of
reduced stress in families utilizing an ABA-based
programme. To address these inconsistencies, this
study assessed whether mothers participating in a
home-based ABA programme reported elevated
depressive symptoms.
Although research focusing on mothers of chil-
dren with disabilities has highlighted the impor-
tance of investigating intervention characteristics
such as intensity (Newsom 1998; Guralnick 2000),
few studies have considered the impact of ABA
intensity on mothers. In one exception, Hastings &
Johnson (2001) investigated the relationship
between parent ABA involvement and family stress
in 141 families of children diagnosed with autism.
Parental involvement was conceptualized as the
hours per week that each parent worked on their
child’s ABA programme. Although they found no
relation between parental intervention involvement
and family stress, the authors did not consider
unmet family needs or the child’s cumulative
involvement in ABA. Building on the work of Hast-
ings & Johnson (2001), this study assessed maternal
depression and ABA intensity.
Measuring intervention intensity is a method-
ological issue present in the ABA literature, with
most studies conceptualizing intensity as child ABA
hours per week (Rogers 1998). However, children
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A. Schwichtenberg & J. Poehlmann • ABA intensity and family outcomes

with an ASD are often involved in ABA pro-
grammes for years, and simply tracking 1 week may
not capture cumulative intensity. Additionally,
addressing only child involvement does not capture
the level of intensity the family may experience. For
this reason, we conceptualized intensity in three
ways: (1) child ABA hours per week, (2) child ABA
hours from the start of their programme, and (3)
maternal ABA hours per week.
In summary, the aims of this study were to
assess: (1) whether mothers participating in a home-
based ABA programme experienced elevated
depressive symptoms; and (2) whether ABA inten-
sity related to unmet family needs and maternal
well-being.
Method
Participants
Forty-one mothers of children diagnosed with an
ASD participated in this study. All eligible families
had been participating in a home-based ABA pro-
gramme for at least 6 months. Families were pre-
dominantly middle class, Caucasian, and married,
with three or fewer children (Table 1). Children in
this study were diagnosed with autistic disorder
(n = 28, 68%), pervasive developmental disorder –
not otherwise specified (n = 11, 27%), and Asperg-
er’s disorder (n = 2, 5%). Children were diagnosed
with an ASD between the ages of 15 months and
6.5 years (mean = 3.13, SD = 1.19). Considering the
potentially problematic nature of having children of
various ages and at various times from diagnosis in
the same sample, child age was controlled for in all
analyses.
Materials
Mothers were asked to complete five questionnaires
focusing on their child’s ASD behaviour presenta-
tion, unmet family needs, feelings of depression,
personal strain and mastery, and their child’s ABA
programme. Descriptive statistics for each question-
naire are provided in Table 2.
Primary stressor: autism spectrum disorder (ASD)
behaviour presentation
Child behaviour presentation was measured using
the Autism Behaviour Checklist (ABC; Krug et al.
1993). The ABC is a 57-item checklist with scores
ranging from 0 to 158, with higher scores reflecting
more ASD behaviours. The ABC has acceptable
reliability (Krug et al. 1979), construct validity
(Eaves et al. 2000) and criterion-related validity
(Bildt et al. 2003).
Secondary stressor: unmet family needs
Unmet family needs were measured using the
Family Needs Survey (FNS; Bailey & Simeonsson
1988). The FNS was designed to assess the needs of
families raising a child with a developmental dis-
ability. The 35-item survey asks parents to answer

Table 1 Sample descriptive statistics

Range

Variable n Minimum Maximum Mean or % SD

Education (years)
Mother 41 12 20 14.8 2.3
Father 41 12 20 14.9 2.4
Age (years)
Mother 41 24 49 37.4 5.7
Child 41 3 14 6.9 2.9
Gender (% male) 41 88%
Race (% Caucasian) 41 90%
Children in home† 41 1 5 2.2 0.9
Income 37 $22 000 $200 000 $76 388 $37 992

†
Includes the target child with an autism spectrum disorder.

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A. Schwichtenberg & J. Poehlmann • ABA intensity and family outcomes

Table 2 Descriptive statistics for maternal

Range report questionnaires (n = 41)

Variable Minimum Maximum Mean SD a

Primary stressor
ABC 3 115 57.8 30.8 0.9
Secondary stressor
FNS 1 30 12.3 7.1 0.9
Mental health outcomes
CES-D 0 37 15.9 11.0 0.9
Personal strain subscale† 9 26 18.1 5.0 0.8
Mastery subscale† 8 20 15.2 3.3 0.7
Resource: intensity indices
Child ABA hours – week‡ 6 50 22.8 10.2
Child ABA hours – 288 11 470 3665 3261
cumulative‡
Mother ABA hours – 0 30 3.1 5.2
week‡

†
From the Impact-on-Family Scale.
‡
From the intervention questionnaire.
ABA, applied behaviour analysis; ABC, Autism Behaviour Checklist; CES-D, Center for
Epidemiological Studies – Depression scale; FNS, Family Needs Survey.

needs-based statements. For example, parents were
asked to respond to I need more information on how
to teach my child. Parents could respond with (1) no,
(2) not sure or (3) yes. Each ‘yes’ response was given
a score of 1, and all needs were then totalled.
Mental health outcomes: depression, personal
strain and mastery
Maternal depressive symptoms were measured
using the Center for Epidemiological Studies –
Depression scale (CES-D), a widely used measure
of depressive symptoms (Radloff 1977). The CES-D
includes 20 statements that assess depressive symp-
toms with scores ranging from 0 to 60, with 16 or
higher indicating higher likelihood of experiencing
clinical depression (Craig & Van Natta 1978). Previ-
ous studies have established reasonable internal
consistency and concurrent validity in the CES-D
(Katz et al. 1995; Skorikov & Vandervoort 2003).
Feelings of personal strain and mastery were
measured using the personal strain (eight-item) and
mastery (five-item) subscales of the Impact-on-
Family Scale (IFS; Stein & Riessman 1980). These
subscales were designed to assess the impact of
raising a child with a chronic illness. Internal con-
sistency and reliability of the entire IFS and its sub-
scales were established by Stein & Riessman (1980)
and Jessop & Stein (1985).
A recent article by Stein & Jessop (2003) reas-
sessed the psychometric properties of the IFS.
Within their article, the authors recommended using
the measure in its entirety rather than the subscales.
The publication of their article coincided with the
data collection period of this study; therefore, this
recommendation could not be followed. Considering
the acceptable internal consistency achieved in this
study (Table 2), the subscales were retained.
Resource
ABA intensity was conceptualized as a potential
resource for children and families. Intensity was
examined using a therapy questionnaire, which
included several questions about the child’s ABA
programme and parental involvement. On the basis
of this questionnaire, three indices of intervention
intensity were generated: (1) child ABA hours per
week, (2) child ABA hours from the start of their
programme, and (3) maternal ABA hours per week.
The maternal ABA intensity index included therapy
hours and therapy preparation.

© 2007 The Authors. Journal Compilation © 2007 Blackwell Publishing Ltd

 Journal of Intellectual Disability Research volume 51 part 8 august 2007
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A. Schwichtenberg & J. Poehlmann • ABA intensity and family outcomes

Procedure Consistent with expectations and previous

Participants were recruited through service provid-
ers in the United States (Minnesota, Wisconsin,
North Carolina and California). Service providers
were asked to distribute explanatory letters and/or
research packets. Across recruitment locations, the
average response rate was 21%. Although this
overall response rate is low, two of the recruitment
locations distributed packets via their general
mailing list, and it is unknown how many families
on the mailing list were participating in ABA.
Therefore, the true response rate is difficult to
determine.
Results
To address our first aim, single-sample t-tests were
used to compare the CES-D scores reported in this
sample (mean = 15.9) with those of samples from
three studies (Abbeduto et al. 2004; Eisenhower
et al. 2005; Blacher & McIntyre 2006). The interven-
tions received by each of the comparison samples
could not be confirmed; therefore, conclusions about
intervention models cannot be drawn on the basis of
this analysis. Rather, comparisons assessed whether
the mothers participating in the current study
reported more depressive symptoms than families
raising children with other developmental disabilities
or mothers in other ASD samples.
research, our sample reported more depressive
symptoms than mothers raising children with Down
syndrome and Fragile X syndrome (Table 3). The
present sample reported more depressive symptoms
than the sample of mothers raising children with
cerebral palsy (CP) in Eisenhower et al. (2005),
although there were no significant differences in
depressive symptoms between the current sample
and CP sample reported in Blacher & McIntyre
(2006). As expected, the present sample reported
depressive symptoms similar to all three ASD com-
parison groups.
To address the relations between ABA intensity
and our variables of interest, a series of multiple
regression analyses were conducted. For each
outcome (i.e. ASD behaviours, unmet family needs,
and maternal feelings of depression, personal strain
and mastery), three models were tested (one for
each intensity index). Within each model, child age
and maternal education (controls) and an intensity
index were entered as predictors.
Although there was a significant correlation
between weekly child ABA hours and cumulative
child ABA hours [r (41) = 0.56, P < 0.01], the sepa-
rate indices were retained, because the index of
cumulative child ABA hours incorporated a dura-
tion component and the other two indices did not.
For maternal ABA hours and cumulative child
ABA hours, log 10 transformations were used prior

Table 3 Single-sample t-tests of maternal CES-D scores (n = 41)

Participants
CES-D
Authors n Diagnosis Mean t (40)

Abbeduto et al. (2004) 174 ASD 12.6 1.91

39 DS 6.7 5.33*
22 Fragile X 11.0 2.83*
Blacher & McIntyre (2006) 23 ASD 13.9 1.15
59 DS 10.2 3.30*
87 CP 12.6 1.91
Eisenhower et al. (2005) 14 ASD 14.9 0.57
12 DS 7.3 4.98*
10 CP 10.9 2.89*

* P < 0.01.
ASD, autism spectrum disorder; CES-D, Center for Epidemiological Studies – Depression scale; CP, cerebral palsy; DS, Down syndrome.

© 2007 The Authors. Journal Compilation © 2007 Blackwell Publishing Ltd

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A. Schwichtenberg & J. Poehlmann • ABA intensity and family outcomes
to analyses to address skewness present in the
distributions.
For unmet family needs and maternal feelings of
mastery, no significant findings emerged for any of
the intensity indices; therefore, the results of these
analyses are not discussed further.
Primary stressor: autism spectrum disorder (ASD)
behaviour presentation
Contrary to expectations, no significant relations
emerged between ASD behaviour presentation and
the two indices of child ABA intensity. For maternal
ABA intensity, the overall model was not significant
(F3,37 = 1.86, P < 0.15), although there was a trend
for mothers of children with more ASD behaviours
to report more ABA involvement (b = 0.31,
P < 0.06). The controls, child age and maternal
education were not significant in these models.
Mental health outcomes
Depressive symptoms
Maternal depressive symptoms related to child ABA
hours per week (F3,37 = 2.94, P < 0.05) (b = -0.36,
P < 0.05) and to child age (b = -0.29, P < 0.05).
Mothers reported fewer depressive symptoms when
their children were older and when their children
participated in more ABA hours per week. Maternal
education was not a significant predictor in this
model. No significant findings emerged for cumula-
tive child or maternal ABA intensity.
Personal strain
No significant relations emerged between maternal
personal strain and the two indices of child ABA
intensity. Although the overall model for maternal
ABA intensity only reached trend-level significance
(F3,37 = 2.77, P < 0.06), the relation between per-
sonal strain and maternal ABA intensity was signifi-
cant (b = 0.36, P < 0.05). Mothers who reported
more hours of ABA involvement reported more per-
sonal strain. Child age and maternal education were
not significant.
Discussion
When considering the relation between ABA inten-
sity and family well-being, two new findings
© 2007 The Authors. Journal Compilation © 2007 Blackwell Publishing Ltd
volume 51 part 8 august 2007
emerged. First, mothers of children with an ASD
reported fewer depressive symptoms when children
were in programmes that included more child ABA
hours per week. This finding is consistent with our
conceptualization of ABA as a potential resource for
children and families. Second, mothers who spent
more hours per week involved in their child’s ABA
programme reported more feelings of personal
strain. This finding highlights the importance of
teasing apart maternal involvement in ABA inter-
ventions from the child’s overall involvement when
examining ABA intensity and family well-being.
Taken together, these findings have direct implica-
tions for intervention implementation. They provide
support for more intense programmes for children
that do not rely too heavily on mothers as therapists
or therapy coordinators. These findings reinforce
previous research on parental involvement wherein
interventionists were encouraged to keep parental
participation individualized and parent initiated
(Turnbull & Turnbull 1982). Additionally, these
findings illustrate the importance of assessing multi-
faceted intensity conceptualizations. Maternal and
child intensity related to different indices of mater-
nal well-being. Future research can build on this by
continuing to develop and test more comprehensive
conceptualizations of intensity.
Considering previous research, the relation
between ABA intensity and maternal depression
and strain could reflect the time that mothers spent
with their child in addition to the child’s ASD
behaviour presentation (Abbeduto et al. 2004). To
assess this third variable explanation, each model
was rerun using ASD behaviour presentation as a
control. Both findings remained, although at a trend
level. Thus, the relations between ABA intensity and
maternal depression and personal strain appear to
be more than simply a function of child ASD
behaviours.
Consistent with the findings of Hastings &
Johnson (2001), families in the present study
reported more depressive symptoms than families
raising children with other developmental disabili-
ties. When compared with other ASD samples,
mothers in the present study reported comparable
depressive symptoms to families raising pre-school
age (Eisenhower et al. 2005), adolescent (Abbeduto
et al. 2004), and young adults with an ASD
(Blacher & McIntyre 2006). However, these com-
 Journal of Intellectual Disability Research
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A. Schwichtenberg & J. Poehlmann • ABA intensity and family outcomes
parisons should be interpreted with caution, given
sample differences (e.g. participant age, sampling
procedures, etc.) and the lack of concrete interven-
tion information for the comparison samples.
When interpreting these findings, limitations of
this study should be noted regarding sample charac-
teristics and measurement procedures. The small
sample size and low response rate, in addition to
sample characteristics such as the wide age range of
children and narrow sociodemographic variation,
limit generalizability of the findings. Participating
families were predominantly Caucasian, middle
class, college educated, and married, although
autism is equally diagnosed across ethnic and socio-
economic classes (Fombonne 2003). The primary
measurement limitation of this study is the exclu-
sive use of maternal report, which may have over-
estimated relations among variables owing to shared
method variance.
Even with these limitations, this study provides
two contributions to the field. First, mothers with
children participating in ABA reported elevated
depressive symptoms, much like any family raising a
child with an ASD, suggesting a potential area for
family-level intervention. Second, ABA intensity
related to maternal depression and personal strain,
and therefore deserves continued attention. Future
studies should attempt to replicate these findings
with a larger and more representative sample and
seek to identify mechanisms through which ABA
intensity may influence family well-being.
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Accepted 31 October 2006