THE ISSUE IS . . .

Applied Behavior Analysis, Autism, and Occupational

Therapy: A Search for Understanding

Christie D. Welch, H. J. Polatajko

MeSH TERMS Occupational therapists strive to be mindful, competent practitioners and continuously look for ways to
 autistic disorder improve practice. Applied behavior analysis (ABA) has strong evidence of effectiveness in helping people
with autism achieve goals, yet it does not seem to be implemented in occupational therapy practice. To better
 behavior therapy
understand whether ABA could be an evidence-based option to expand occupational therapy practice, the
 goals authors conducted an iterative, multiphase investigation of relevant literature. Findings suggest that occu-
 occupational therapy pational therapists apply developmental and sensory approaches to autism treatment. The occupational ther-
apy literature does not reflect any use of ABA despite its strong evidence base. Occupational therapists may
currently avoid using ABA principles because of a perception that ABA is not client centered. ABA principles
and occupational therapy are compatible, and the two could work synergistically.

Welch, C. D., & Polatajko, H. J. (2016). The Issue Is—Applied behavior analysis, autism, and occupational therapy: A
search for understanding. American Journal of Occupational Therapy, 70, 7004360020. http://dx.doi.org/10.5014/
ajot.2016.018689

Christie D. Welch, OT Reg. (Ont.), is PhD Student,

Rehabilitation Sciences Institute, Faculty of Medicine,
University of Toronto, Toronto, Ontario, Canada; christie.
welch@mail.utoronto.ca
H. J. Polatajko, PhD, OT Reg. (Ont.), OT(C),
FCAOT, FCAHS, is Editor-in-Chief, Canadian Journal of
Occupational Therapy; Professor, Department of
Occupational Science and Occupational Therapy,
Rehabilitation Sciences Institute, Neuroscience Program,
University of Toronto; and Program Affiliate, St. John’s
Rehab Hospital, Toronto, Ontario, Canada.
T his article presents a literature-based
argument for the use of applied behavior
analysis (ABA) in occupational therapy
practice. In doing so, we describe the
relevant literature to determine the extent
to which ABA is used, consider possible
reasons for not using it, and make the case
that strong compatibility exists between
the principles of ABA and occupational
therapy and that the two could work
synergistically.
Background
Occupational therapy is one of the most
common services received by people
(especially children) with autism spectrum
disorder (ASD; McLennan, Huculak, &
Sheehan, 2008). Occupational therapists
contribute to the diagnostic process and
support and educate families in a variety of
settings, using their expertise to enable
engagement in occupations such as play,
self-care, school activities, and employment
(American Occupational Therapy Associa-
tion [AOTA], 2015; Rodger & Polatajko,
2014). Services based on ABA principles
are also among the treatment options most
frequently sought by people with autism
(Matson, Turygin, et al., 2012).
The literature pertaining to autism
treatment is vast (Matson, Turygin, et al.,
2012), and both occupational therapy and
ABA perspectives can be found. Despite
overlap in the areas of function addressed by
ABA and occupational therapy, we found al-
most no overlap in these literatures: Although
the ABA literature (journals in the field of
behavioral science) makes occasional refer-
ence to occupational therapy, the occupa-
tional therapy literature is silent on the topic
of ABA (a literature search yielded only one
article mentioning ABA, which was published
in 1996 and related to feeding interventions
for adults with acquired brain injury).
We found this silence intriguing, so
we set out to understand the relationship
between occupational therapy treatment
approaches to autism and the ABA ap-
proach. We undertook a staged approach:
asking and answering a series of questions
to lead to an understanding of the absence
of ABA in occupational therapy practice, as
reflected in the literature. In so doing, we
saw the emergence of an argument for the
development of a synergistic relationship

The American Journal of Occupational Therapy 7004360020p1

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 between occupational therapy perspectives
on ASD intervention and principles of ABA
intervention.
This article presents our findings in
the hope that occupational therapy prac-
titioners will consider applying princi-
ples of ABA in their work and use their
knowledge base to develop a synergy be-
tween occupational therapy approaches and
ABA. The hope is also that occupational
therapy research will explore this topic
directly because ABA’s absence from the
occupational therapy literature may be tac-
itly suggesting that occupational therapy
practitioners should avoid it in practice.
Exploration in the literature can spark im-
portant discourse (within and between dis-
ciplines) and begin the cycle of application,
evaluation, and revision.
Perspectives on Autism
Treatment
In the general literature on ASD, ABA is
the predominant approach to interven-
tion. It is broadly considered the preferred
treatment approach, even at the level of
government—it is recognized and supported
by the governments of Canada, Australia,
and the United States (Dillenburger,
McKerr, & Jordan, 2014). This support
is based on the wealth of available evidence,
recently summarized by Anagnostou et al.
(2014) in a review article published in
the Canadian Medical Association Journal.
These authors examined evidence related
to diagnosis as well as to biomedical and
nonbiomedical treatments. With respect
to nonbiomedical treatments, Anagnostou
et al. synthesized six meta-analyses and
found that ABA-based approaches showed
the strongest effects in treating symptoms
of ASD and achieving therapeutic goals.
Moreover, approaches based on ABA prin-
ciples were found to have the highest level of
evidence. An interesting finding was that
the benefits of ABA approaches were maxi-
mized when implemented in everyday
contexts and included activities based on
children’s interests.
!In the occupational therapy literature
on autism, the predominant approaches
to intervention are derived from sensory
processing, sensory integration, and de-
velopmental perspectives. Two articles
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looked at the way occupational therapists
approach working with clients with ASD.
Kadar, McDonald, and Lentin (2012) ex-
amined the ways in which occupational
therapy practices changed over time from
2002 to 2012. Occupational therapists in
this study reported high use of theories, as-
sessments, and interventions based on sen-
sory integration, and this use remained
consistent over the 10 years under review.
Ashburner, Rodger, Ziviani, and Jones
(2014) looked at surveys from 818 occu-
pational therapists practicing in Queens-
land, Australia. Of these therapists, 235
identified that they work with clients who
have autism. Among the occupational
therapists working in the field of ASD, the
prevalent focus was on sensory processing in
relation to assessment, intervention, and
primary areas of knowledge. Therapists also
reported using general developmental ap-
proaches as well as visual supports, though
to a lesser extent.
Understanding the Difference
When discussing occupational therapy, the
ABA literature seems to focus on occupa-
tional therapists’ use of sensory integration
approaches (Devlin, Healy, Leader, &
Hughes, 2011; Matson, Adams, Williams,
& Rieske, 2013; McGinnis, Blakely,
Harvey, Hodges, & Rickards, 2013; Schreck
& Miller, 2010) and illustrates a somewhat
conflicted perception. On the one hand,
a number of ABA therapists report using
sensory integration in their practice
(Schreck & Miller, 2010). On the other
hand, articles can be found that warn
ABA therapists against this practice (Devlin
et al., 2011; Matson et al., 2013; Schreck &
Miller, 2010). This tension highlighted in
the ABA literature is echoed in the broader
autism literature, which frames sensory in-
tegration therapy as complementary or al-
ternative medicine (Hanson et al., 2007)
and occasionally references the policy state-
ment issued by the American Academy of
Pediatrics that urges physicians to advise
patients and parents that the evidence of
effectiveness for sensory-based therapies
is limited and inconclusive (Zimmer &
Desch, 2012).
As mentioned earlier, ABA is not dis-
cussed in the occupational therapy literature.
A conclusive reason for this omission re-
mains elusive, because there is no discourse
to examine. To uncover possible reasons,
we turned to literature focusing on criti-
cism of ABA. We found that ABA suffers
from widespread reputational problems,
even stigma, secondary to widespread
misperceptions held by a variety of pro-
fessionals, presumably including occupa-
tional therapists (Gambrill, 2012; Matson,
Turygin, et al., 2012; Schreck & Miller,
2010). The ABA literature has identified
three primary reputational problems: (1)
Many professionals working outside the
field of ABA misunderstand it as being
limited to discrete trial training, (2) it is
perceived to fail to consider generalization,
and (3) it is perceived to fail to consider cli-
ent desires and interests (Gambrill, 2012;
Matson, Turygin, et al., 2012; Schreck &
Miller, 2010). These reputational problems
offer a quite plausible explanation for the ab-
sence of ABA in occupational therapy prac-
tice and literature. To practitioners, evidence
(such as that supporting ABA) is necessary but
not sufficient for a treatment approach to
be embraced by the profession (Townsend &
Polatajko, 2007). Occupational therapists
insist on using strategies that are evidence
based, client centered, and focused on func-
tion (Townsend & Polatajko, 2007).
The ABA literature has addressed
ABA’s three primary reputational myths:
(1) ABA is in fact a broad science that is
concerned with the causes of socially sig-
nificant behaviors and is applied through
many tools, of which discrete trial training
is just one (Cooper, Heron, & Heward,
2007; Sigafoos & Schlosser, 2008); (2)
ABA stresses planning for generalization of
skills across people, settings, and time from
the first day of treatment (Cooper et al.,
2007); and (3) ABA identifies social val-
idity (how the client feels about targets,
procedures, and people involved) as being
vitally important (Wolf, 1978). Further-
more, it focuses on building a behavioral
repertoire to increase client choice by
increasing skills to draw from (Gambrill,
2012). Because the ABA literature describes
these perceptions of ABA as mispercep-
tions, it is useful to examine the literature
to determine whether ABA principles may
possibly be applied in client-centered,
occupation-focused intervention.
July/August 2016, Volume 70, Number 4
 Compatibilities Between
Literature on Applied Behavior
Analysis and the Occupational
Therapy Literature
Points of intersection can be found between
the occupational therapy and the ABA
literatures. The occupational therapy liter-
ature stresses the importance of a strengths-
based approach to practice (Townsend &
Polatajko, 2007). The ABA literature also
emphasizes using a strengths-based ap-
proach to build the skills of clients and
significant others (Gambrill, 2012). Rather
than focusing only on extinguishing un-
wanted behaviors, ABA applies a learning
paradigm to change. This paradigm in-
cludes creating behavior and skill repertoires
such as those that compete with undesired
behaviors (Schwartz & Goldiamond, 1975,
as cited in Gambrill, 2012).
The occupational therapy literature
emphasizes consideration for social and
cultural context, seeing that people shape
and are shaped by their environments
(Townsend & Polatajko, 2007). So, too,
does the ABA literature. Attention to
context and environmental influences is
identified as a key characteristic of ABA
(Gambrill, 2012). In their 1987 founda-
tional article, Baer, Wolf, and Risley de-
scribed ABA as concerned with “behaviors
of the client that trouble that person; but
more often, also behaviors of people other
than the client” (p. 314).
Both the occupational therapy and the
ABA literatures identify the importance of
making decisions collaboratively (Baer et al.,
1987; Townsend & Polatajko, 2007). For
example, they both recommend planning
goals and related interventions directly with
clients as much as possible: collaboratively
choosing target goals, identifying general-
ization strategies, and choosing reinforcers
(Ontario Association for Behavior Analysis,
2010; Townsend & Polatajko, 2007).
The occupational therapy and the
ABA literatures contain similar guidelines
pertaining to the prioritization of goals.
The U.S. Behavior Analyst Certification
Board (2012) has recommended that prac-
titioners prioritize client behaviors and skills
that (1) may threaten the health or safety of
self or others; (2) may be a barrier to their
inclusion in important activities or settings;
The American Journal of Occupational Therapy
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(3) limit participation in family and com-
munity life; and (4) are developmentally
appropriate adaptive, social, or functional
skills that are fundamental to health, social
inclusion, and independence. For example,
when working on a developmental skill,
therapists must consider its current function
and future value to both the individual and
his or her community. The emphasis on
participation expressed by the U.S. Behavior
Analyst Certification Board is aligned with
the Canadian Process Practice Framework
for occupational therapy (Davis, Craik, &
Polatajko, 2007) and the Occupational
Therapy Practice Framework: Domain
and Process (3rd ed.; AOTA, 2014).
The ABA literature supports the
implementation of a mediator model: one
that supports the client with ASD by
supporting, educating, and coaching the
important people in his or her life (Matson,
Hattier, & Belva, 2012). The ABA literature
has shown that schoolteachers, early child-
hood educators, parents, and health care
professionals can learn to effectively apply
the principles of ABA. The occupational
therapy literature also supports this model as
an effective, efficient, and client-centered
way of practice (Case-Smith & Arbesman,
2008; Rodger & Polatajko, 2014).
Comparison of the occupational ther-
apy and the ABA literatures suggests that
the two approaches can actually be com-
bined to enhance outcomes. Because many
occupational therapists express a desire to
improve their practice with clients who
have autism (Ashburner et al., 2014), it
seems worth considering how application of
ABA principles may improve occupational
therapy outcomes as well as how an occu-
pational therapy perspective can maximize
the benefits of ABA.
Synergy Between Applied
Behavior Analysis and
Occupational Therapy
Application of ABA principles has the
potential to enhance occupational therapy
intervention on the basis of ABA’s effec-
tiveness in addressing several areas rele-
vant to occupational therapy. Matson,
Hattier, and Belva (2012) found inter-
ventions based on ABA to be effective in
promoting work skills, self-care, play and
leisure, and peer engagement and in mini-
mizing the disruption of sensory behaviors
(Matson, Hattier, & Belva, 2012). These
areas are the very areas addressed by oc-
cupational therapy practitioners serving
people with autism (Rodger & Polatajko,
2014). Occupational therapy practice can
augment ABA outcomes because it offers
features not typically considered in ABA.
Occupational therapy practitioners value
playfulness and can build a rich play expe-
rience while working on component skills
of play. In addition, occupational therapy
practitioners implement strategies in real-
life contexts using naturalistic techniques
(Spitzer, 2008).
One critical component of occupa-
tional therapy practice that lies outside
ABA is its holistic perspective, particularly
practitioners’ skill in analyzing people’s
behaviors and occupational performance
on multiple levels (as described in the
Fit chart; Polatajko, 2007, as cited in
Townsend & Polatajko, 2007, p. 213). Al-
though modern-day ABA scientists go be-
yond the observable and consider a person’s
thoughts, feelings, desires, and calcula-
tions (Cooper et al., 2007), occupational
therapists carry out a much broader analysis
because they are trained in assessing and
addressing performance components such
as transitions, sensory differences, social
skills, and motor issues (Rodger & Polatajko,
2014). Occupational therapy practitioners
can identify and address a person’s diffi-
culties with executive functioning, sen-
sory processing, physiological self-regulation
(Cramm, Krupa, Missiuna, Lysaght, &
Parker, 2013), anxiety, phobias (Chugh-
Gupta, Baldassarre, & Vrkljan, 2013), and
components of movement such as praxis
and strength (Rodger & Polatjko, 2014).
Examples include selecting reinforcers on
the basis of an understanding of tactile
responses and conducting performance
analysis on the basis of an understanding
of reflex patterns.
This deeper analysis also extends to
occupational therapy practitioners’ under-
standing of the environment. The Cana-
dian Model of Occupational Performance
and Engagement (Townsend & Polatajko,
2007) defines the environment as having
cultural, institutional, physical, and so-
cial elements that can enable or constrain
7004360020p3
 occupational performance. Looking at the
environment in this way makes practitioners
particularly adept at developing antecedent
strategies—those that set the client up for
success. Examples include coaching peers in
effective ways to socially engage a child with
ASD, reducing the sensory demands of the
environment, and educating teachers about
the characteristics of ASD so that they are
more accepting of certain behaviors.
Principles of ABA can be applied for
more effective and evidence-based imple-
mentation of sensory-based strategies. For
instance, ABA principles would suggest
that timing of sensory input strategies is
critical (Cooper et al., 2007), for example,
when a client demonstrates unwanted be-
haviors, such as striking him- or herself
or someone else, and then immediately
receives sensory input meant to calm him
or her (e.g., a familiar person comes and
applies deep pressure to the client’s shoul-
ders). This application of a sensory-based
strategy could inadvertently reinforce the
striking behavior, leading to its increase. An
occupational therapist with this insight can
instruct caregivers to implement calming
strategies at the first signs of agitation, before
undesired behavior is demonstrated.
Directions for Action: Clinical and
Research
Occupational therapists seeking to enhance
their application of a developmental ap-
proach to working with clients who have
ASD can look to literature on the Early Start
Denver Model. This model is an approach
to autism treatment that is based on both
developmental science and behavioral sci-
ence (Rogers et al., 2006). It is also advisable
to look into pivotal response training, an ap-
proach based on ABA that uses naturalistic
and play-based methods and is well sup-
ported by evidence (Koegel, 2000; Rogers
et al., 2006). In their 2005 book Is It Sensory
or Is It Behavior? Murray-Slutsky and Paris
explored ways to draw from behaviorist
theory and incorporate it into all phases of
occupational therapy practice.
Because occupational therapists re-
port finding little help in the literature
(Ashburner et al., 2014), more literature re-
lated to ASD from an occupational therapy
perspective is needed. Additional systematic
7004360020p4
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reviews on interventions for ASD, also from
an occupational therapy perspective, would
be helpful so that clinicians can access in-
formation on levels of evidence in a time-
efficient way. The field could benefit from
research that directly explores why occupa-
tional therapists use the approaches they do
when working with clients who have ASD.
Research directly investigating practitioners’
use of ABA principles could better elucidate
the benefits and risks of this application.
Conclusion
Examining the relevant literature revealed
that current trends in occupational therapy
approaches to autism intervention diverge
from predominant approaches in the field.
The ABA literature suggests that there are
widely held misperceptions of ABA as not
being client centered, which is a plausible
explanation for its absence from the occu-
pational therapy literature and practice.
However, because ABA is an approach sup-
ported by strong evidence (Anagnostou et al.,
2014; Reichow, Barton, Boyd, & Hume,
2012), it has the potential to improve occu-
pational therapy outcomes. In addition,
occupational therapy practitioners possess
analysis skills that make them well suited to
adapt ABA principles within a broader ap-
proach. Therefore, practitioners must mind-
fully evaluate the potential of applying ABA
within occupational therapy practice. Con-
tending with this issue can bring improve-
ments to occupational therapy practice and to
ABA practice and, most important, can im-
prove outcomes for clients with ASD. s
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