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UNDERSTANDING AUTISM
Evidence-Based Interventions

Foundational

• FBA
• Reinforcement
• Prompting
• Time Delay
• Extinction
• FCT, DR, RIR, ABI, TA

Approaches

• DTT, PRT, NI, CBI

• Parent-implemented
• Peer-mediated
• PECS

Tools

• Visual supports
• Scripting
• Social stories
• Modeling/video modeling
• TAII (e.g., SGD)

ABA Approach to Teaching

• Focus on antecedents (what happens before) and
consequences (what happens after) of a behavior
• Teach skills to replace problem behaviors
• Increase positive behavior and reduce interfering behavior
• Change responses to child’s behavior
• Increase academic, cognitive, social and self-help skills
• Improve focus, compliance and motivation so that children are
more available to learn
• Focus on maintenance & generalization of skills
• Parents are taught to use strategies outside of the therapy setting

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Functional Behavioral Assessment (FBA)

• 10 single case design studies
• Used to understand the function or purpose of a specific
interfering behavior
• IDEA states that a behavior intervention plan based on a FBA
should be considered when developing the IEP if the student’s
behavior interferes with his/her learning or learning of classmates

A[ntecedent]-B[ehavior]-C[onsequence]
Behavior: interfering behavior that is most problematic for
the learner
• Note: Any behaviors that create safety concerns for the learner or
others should be addressed first

A[ntecedent]-B[ehavior]-C[onsequence]
Antecedents: Ask the “Wh” questions:
• Where?
• With whom?
• When?
• What activity?
• What are other students doing?
• What is the teacher doing?

Environmental contributing factors: Staff, Proximity of others, Noise

level, Group size

More distal events: Medication change, Changes or distress in home

life, Health status of student

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A[ntecedent]-B[ehavior]-C[onsequence]
Consequences
• Multiple events may follow the behavior of concern (e.g., adult
provided attention and then removed or modified a task)
• Thus, multiple occurrences of ABC data is required

Function of Behavior
The function of a behavior refers to the source of
environmental reinforcement (events that maintain or
increase the likelihood of behavior occurring).

4 main functions of behavior is “Everybody EATS”

E = Escape or avoidance; A = Attention; T = Tangibles or
Activities; S = Sensory Stimulation
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1. Does the problem behavior occur when the Yes No N/A

FBA
person is not receiving attention or when
caregivers are paying attention to someone else?
FAST 2. Does the problem behavior occur when the
person’s requests for preferred items or
Yes No N/A

_____________ activities are denied or when these are taken

away?
3. When the problem behavior occurs, do care- Yes No N/A
Functional Analysis Screening Tool givers usually try to calm the person down or
involve the person in preferred activities?
4. Is the person usually well behaved when (s)he Yes No N/A

The Functional
Client:_________________________________ Date:_____________ is getting lots of attention or when preferred

•
activities are freely available?
Informant:__________________ Interviewer:___________________
5. Does the person usually fuss or resist when Yes No N/A
To the Interviewer: The FAST identifies factors that may influence (s)he is asked to perform a task or to participate
in activities?

Assessment Screening
problem behaviors. Use it only for screening as part of a comprehensive
functional analysis of the behavior. Administer the FAST to several 6. Does the problem behavior occur when the Yes No N/A
individuals who interact with the client frequently. Then use the results person is asked to perform a task or to
to guide direct observation in several different situations to verify participate in activities?
suspected behavioral functions and to identify other factors that may 7. If the problem behavior occurs while tasks are Yes No N/A

Tool (FAST; Iwata &

influence the problem behavior. being presented, is the person usually given a
“break” from tasks?
To the Informant: Complete the sections below. Then read each
question carefully and answer it by circling "Yes" or "No." If you are 8. Is the person usually well behaved when (s)he Yes No N/A

deLeon, 1995):
uncertain about an answer, circle “N/A.” is not required to do anything?

Informant-Client Relationship 9. Does the problem behavior occur even when no Yes No N/A
1. Indicate your relationship to the person: ___Parent ___Instructor one is nearby or watching?
___Therapist/Residential Staff ______________________(Other) 10. Does the person engage in the problem behavior Yes No N/A
2. How long have you known the person? ____Years ____Months even when leisure activities are available?

Used to determine the

3. Do you interact with the person daily? ____Yes ____No

• 4. In what situations do you usually interact with the person?

___ Meals ___ Academic training
___ Leisure ___ Work or vocational training
11. Does the problem behavior appear to be a form
of “self-stimulation?”
Yes No N/A

potential cause(s) of the ___ Self-care ___________________________________(Other) 12. Is the problem behavior less likely to occur Yes No N/A
when sensory stimulating activities are
Problem Behavior Information presented?
1. Problem behavior (check and describe): 13. Is the problem behavior cyclical, occurring for Yes No N/A

behavior.
__ Aggression ________________________________________ several days and then stopping?
__ Self-Injury _________________________________________
14. Does the person have recurring painful Yes No N/A
__ Stereotypy _________________________________________
__ Property destruction __________________________________ conditions such as ear infections or allergies?
__ Other _____________________________________________ If so, list:_____________________________

• Raters are asked to 2. Frequency: __Hourly __Daily __Weekly __Less often

3. Severity: __Mild: Disruptive but little risk to property or health
__Moderate: Property damage or minor injury
15. Is the problem behavior more likely to occur
when the person is ill?
Yes No N/A

__Severe: Significant threat to health or safety 16. If the person is experiencing physical problems, Yes No N/A

answer 18 yes/no 4. Situations in which the problem behavior is most likely to occur:
Days/Times____________________________________________
Settings/Activities ______________________________________
and these are treated, does the problem behavior
usually go away?

questions
Persons present ________________________________________
5. Situations in which the problem behavior is least likely to occur: Scoring Summary
Days/Times____________________________________________
Settings/Activities ______________________________________ Circle the number of each question that was answered “Yes” and
Persons present ________________________________________ enter the number of items that were circled in the “Total” column.

4 categories of function:
6. What is usually happening to the person right before the problem

• behavior occurs?________________________________________
______________________________________________________
______________________________________________________
Items Circled “Yes”

1 2 3 4
Total

____
Potential Source of Reinforcement

Social (attention/preferred items)

attention, escape, 7. What usually happens to the person right after the problem
behavior occurs?________________________________________
______________________________________________________
5 6 7 8 ____ Social (escape from tasks/activities)
______________________________________________________

sensory, pain attenuation 8. Current treatments_______________________________________ 9 10 11 12 ____ Automatic (sensory stimulation)

______________________________________________________
______________________________________________________ 13 14 15 16 ____ Automatic (pain attenuation)
______________________________________________________
______________________________________________________ © 2005 The Florida Center on Self-Injury

Antecedent-based Intervention (ABI)

• 32 single case design studies
• GOAL: identify the conditions in the setting that are reinforcing the
interfering behavior and then to modify the environment or activity so
that the environmental conditions no longer elicit the interfering
behavior
• Possible ABI strategies include:
• Using learner preferences (include highly-preferred items within a non-preferred
activities to prevent learners from wanting to escape or avoid the activity)
• PREMACK PRINCIPLE – IF -> THEN
• Changing schedules/routines (create predictable schedules)
• VISUAL SUPPORTS
• Using choice-making (offer choices to increase learners control of a situation);
• Enriching the environment with sensory stimuli (provide access to preferred sensory
stimuli)

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Antecedent-based Intervention (ABI)

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Antecedent-based Intervention (ABI)

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Reinforcement (R+)
• 43 single case design studies
• Reinforcement describes the relationship between learner behavior
and a consequence that follows the behavior. The relationship
between the learner’s use of a skill/behavior and the consequence is
only reinforcing if the consequence increases the likelihood the
learner performs the skill or behavior
• Positive, negative, token economy

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Prompting
• 32 single case design studies
• Prompting includes any help given to a
learner that assists the learner in using a
specific skill or behavior.
• Sometimes referred to as an errorless
learning method, prompting reduces
incorrect responding as learners acquire
new skills.

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Time Delay
• 10 single case design studies
• Prompt dependence limits a learner’s ability to generalize skills to
new situations, activities, and individuals
• Prompt dependence can be prevented by using time delay. Time
delay is a response prompting procedure that systematically fades
prompts during instructional activities

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Differential Reinforcement (DR)

• 25 single case design studies
• Differential reinforcement decreases interfering or challenging
behaviors
• Differential reinforcement reinforcers learners for:
• not engaging in the interfering behavior (DRO)
• spending less time engaged in the interfering behavior (DRL)
• and/or spending time engaged in more appropriate behavior choices (DRA/DRI)

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Differential Reinforcement (DR)

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Extinction
• 10 single case design studies
• Behavioral procedure that results in the reduction or elimination of a
behavior when an individual stops receiving reinforcement for
engaging in that behavior
• Not appropriate in all cases:
• Is the behavior to be extinguished one that is likely to be imitated
by other learners in the class?
• Does the student engage in self-injurious, destructive, or
aggressive behavior when frustrated or angry?
• Are there times when it will not be feasible to withhold the
maintaining consequence for the behavior?

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Functional Communication Training (FCT)

• 12 single case design studies
• Functional communication training addresses these interfering
behaviors by systematically identifying the function of the behavior
and providing a replacement behavior in the form of appropriate
communication that will enable the learner to get his or her needs met
in a more acceptable way

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Five Parts to a Trial in DTT (Smith, 2001)

• Teacher presents brief, distinctive instruction or question
• e.g., “do this”, “what is it?”
• If needed, a prompt is provided after or along with the
instruction
• Child responds correctly or incorrectly
• Teacher provides a consequence (reinforcer, ignore, or
correction)
• Intertrial Interval
• Teacher pauses 1-5 s before presenting the next trial
• Data may be recorded at this time

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Used Children less that 4 years old; intensive 40 hours/week

365 days a year

Treatment group Control group

(post-treatment): (post-treatment):
47% in average range for IQ 2% in average range for IQ
40% in mild ID range 40% in mild ID range
10% in profound ID range 53% in profound ID range

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Naturalistic Intervention
• 10 single case design studies
• Naturalistic intervention integrates the principles of ABA into the
natural environment, or into a learner’s everyday routines and
activities so that the acquired skills may be more easily generalized

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Differences Between IT and DTT

Discrete Trial Training Incidental Teaching

Teacher-initiated Child-initiated

Structured learning Natural environment

environment
Teacher-selected Child-selected materials
materials and reinforcers and reinforcers

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Floortime / Relationship Development

Intervention
• Floortime (developmental, individual-difference, relationship-based; DIR)
• Adults help children to expand circle of communication by meeting child at their
developmental level and building on strengths
• Focus on 6 developmental areas:
• Self-regulation and interest in the world
• Intimacy and engagement
• Two-way communication
• Complex communication
• Emotional ideas
• Emotional thinking

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Greenspan (DIR; Floortime)

• DIR/Floor Time includes interactive experiences,
which are child-directed, in a low stimulus
environment, ranging from two to five hours a day
• During a preschool program, DIR/Floor Time
includes integration with typically-developing
peers
• Greenspan contends that interactive play, in
which the adult follows the child's lead, will
encourage the child to "want" to relate to the
outside world (Greenspan, 1998)

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Early Start Denver Model

• Comprehensive behavioral early intervention for
children 12-48 months
• Integrates relationship-focused developmental model with
principles of ABA
• Naturalistic and behavior analytic strategies
• Sensitive to normal developmental sequence
• Significant parental involvement
• Focus on interpersonal exchange and affect
• Shared engagement with joint activities
• Language and communication taught within a positive,
affect-based relationship
• Evidence-based for children with a wide range of learning
abilities and styles

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Early Start Denver Model

• Focus: social orientation, attention, affect sharing and
attunement, imitation, joint attention, language
development, and functional and symbolic play
• The ESDM has an interactive communication- and relationship-
based framework that fosters active experiential learning by
supporting child spontaneity and initiative

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Journal of Autism and Developmental Disorders (2022) 52:2838–2853

https://doi.org/10.1007/s10803-021-05137-y

COMMENTARY

Concerns About ABA-Based Intervention: An Evaluation

and Recommendations
Justin B. Leaf1 · Joseph H. Cihon1 · Ronald Leaf1 · John McEachin1 · Nicholas Liu2 · Noah Russell1 · Lorri Unumb3 ·
Sydney Shapiro4 · Dara Khosrowshahi4

Accepted: 6 June 2021 / Published online: 16 June 2021

© The Author(s) 2021

Abstract
For over 50 years, intervention methods informed by the principles of applied behavior analysis (ABA) have been empirically
researched and clinically implemented for autistics/individuals diagnosed with autism spectrum disorder (ASD). Despite the
plethora of evidence for the effectiveness of ABA-based interventions, some autism rights and neurodiversity activists have
expressed concerns with ABA-based interventions. Concerns have included discontent with historical events and possible
harm from the procedures and goals targeted. The purpose of this manuscript is to examine some expressed concerns about
ABA-based intervention and suggest productive ways of moving forward to provide the best outcomes for autistics/individuals

35 diagnosed with ASD. The authors represent stakeholders from multiple sectors including board certified behavior analysts,
licensed psychologists, parents, and autistics/individuals diagnosed with ASD.

Keywords Autism · Abuse · Behavioral intervention · Early intensive behavioral intervention · Self-stimulatory behavior

Concerns About ABA-Based Intervention:

An Evaluation and Recommendations

Wolf and colleagues (1964) provided one of the first empiri-

cal evaluations of the application of behavior analytic prin-
ciples to address the behavior of autistics/individuals diag-
* Justin B. Leaf nosed with autism spectrum disorder1 (ASD). In this seminal
Jblautpar@aol.com
study, Wolf and colleagues examined the effectiveness of
Joseph H. Cihon several operant conditioning procedures (e.g., extinction,
jcihon@autismpartnership.com
shaping) to decrease the frequency of interfering behavior
Ronald Leaf (e.g., tantrums) and increase the frequency of pro-social
Rlautpar@aol.com
PFI_12mmX178mm.pdf
John McEachin
+ eps format behavior (e.g., wearing glasses, bedtime behavior, commu-
nication skills) for a young autistic boy2 who was at risk
Jmautpar@aol.com
14697610, 2021, 1, Downloaded from https://acamh.onlinelibrary.wiley.com/doi/10.1111/jcpp.13249 by Purdue University (West Lafayette), Wiley Online Library on [18/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

of permanent vision loss and institutional placement. The

Nicholas Liu results of the study indicated that the procedures, based on
nliu1@uchicago.edu
Journal of Child Psychology and Psychiatry 62:1 (2021), pp 5–15 behavior analytic principles, were effective for developing
doi:10.1111/jcpp.13249
Noah Russell a variety of skills and ameliorating interfering behavior.
noahrussell@verizon.net
Furthermore, six months following the study the partici-
Lorri Unumb pant’s mother reported that her son “continues to wear his
Research Review: Conflicts of Interest (COIs) in autism
lorri.unumb@gmail.com
glasses, does not have tantrums, has no sleeping problems,
early
1
intervention
Autism Partnership Foundation, 200 Marina research
Seal Beach, CA 90740, USA
Drive, – This
a meta-analysis
terminology was selected to adhere of
1
to the 7COI th
edition of the
American Psychological Association Publication Manual and to be
2 influences
University of California, on intervention
Santa Barbara, CA, USA effects
inclusive of those who prefer person-first as well as identity-first lan-
3
guage.
Parent, Columbia, SC, USA 2
When discussing prior research, the terminology used within that
4 1 1
Parent, Seal Beach,
Kristen CA, USA
Bottema-Beutel, Shannon research
Crowley, Micheal Sandbank,2
is used. and
Tiffany G. Woynaroski3
1
Lynch School of Education and Human Development, Boston College, Chestnut Hill, MA, USA; 2Department of
13
Vol:.(1234567890)
3
Special Education, University of Texas at Austin, Austin, TX, USA; Vanderbilt Brain Institute, Vanderbilt Kennedy
Center, Vanderbilt University Medical Center, Nashville, TN, USA

Background: The presence, types, disclosure rates, and effects of conflicts of interest (COIs) on autism early
intervention research have not previously been studied. The purpose of this study was to examine these issues.
Methods: This study is a secondary analysis of a comprehensive meta-analysis of all group-design, nonpharma-
cological early intervention autism research conducted between 1970 and 2018. We coded reports for the presence/
absence of COI statements, the types of COIs that were disclosed, and for 8 types of COIs, including (a) the author
developed the intervention, (b) the author is affiliated with a clinical provider, (c) the author is employed by a clinical
provider, (d) the author is affiliated with an institution that trains others to use the intervention, (e) the author
receives payment or royalties related to the intervention, (f) the study was funded by an intervention provider, (g) the
study used a commercially available measure developed by the author, and (h) proceeds of the intervention fund the

36
author’s research. Frequencies and proportions were calculated to determine prevalence of COIs and COI
disclosures. Meta-analysis was used to estimate summary effects by COI type and to determine if they were larger
than for reports with no coded COIs. Results: Seventy percent of reports were coded for ≥ 1 COI, but only ~ 6% of
reports contained COI statements fully accounting for all coded COIs. Metaregressions did not detect significant
influences of any COI type on summary effects; however, point estimates for each COI type were larger than for
reports with no coded COIs. Conclusions: Conflicts of interest are prevalent but under-reported in autism early
intervention research. Improved reporting practices are necessary for researcher transparency and would enable
more robust examination of the effects of COIs on research outcomes. Keywords: Autism; early intervention;
conflicts of interest; meta-analysis.

(i.e., benefits have already occurred or are continu-

Introduction
ing to occur), or perceived (i.e., there are no potential
Conflicts of interest (COIs) occur when researchers
or actual benefits that have accrued or could accrue
stand to benefit from studies that show particular
to the author, but such benefits are a reasonable
outcomes (Gorman, 2018; Institute of Medicine,
Foundational perception). While the most discussed types of COIs
2002). In this circumstance, researcher conduct in
are those that involve direct financial transactions,
service of producing high quality, objective research
they also extend to professional or personal relation-
may be compromised by competing interests such as
• FBA ships, ideological commitments, and religious or
advancing one’s career or receiving immediate finan-
political views (Eisner, 2009; Goozner et al., 2009).
cial• incentives
Reinforcement
(Romain, 2015). Researcher conduct
The potential for biases resulting from the many
can refer to a variety of activities, such as those
• Prompting
involved in designing the study, recruiting and
types of COIs exists regardless of whether research-
• Timeparticipants
allocating Delay to treatment and control ers believe that their research activities are influ-
enced by COIs (Goozner et al., 2009). The existence
• Extinction
groups, data analysis, and interpreting and report-
of COIs does not necessarily indicate that the com-
ing study findings. Bias stemming from COIs can
lead• to
FCT, DR, that
activities RIR,threaten
ABI, TA research integrity,
peting interests influenced the researcher, only that
the potential for bias is present.
such as preferentially sorting participants into the
In research fields such as medicine, public
treatment group, selecting measures that are vul-
Approaches
nerable to placebo effects, or engaging in ‘fishing’ or
health, substance abuse prevention, and criminol-
ogy, meta-analyses have been conducted to inves-
‘p-hacking’ to search for significant findings (Eisner,
tigate the influence of COIs on effect sizes reported
• DTT,
2009; Gandhi PRT,
et al.,NI, CBI
2007; Ioannides et al., 2014).
in intervention studies. This work has shown that
Conflicts of interest can be potential (i.e., benefits
have• not
Parent-implemented
yet occurred or are not occurring at the time
studies conducted by researchers with COIs are
more likely to show positive findings than studies
• Peer-mediated
of research but could occur in the future), actual
conducted by researchers who do not have COIs
• PECS (Cherla et al., 2019; Chivers, 2019; Delgado &
Conflict of interest statement: See Acknowledgements for full Delgado, 2017; Wells, 2017). In the medical field,
disclosures.
Tools
© 2020 Association for Child and Adolescent Mental Health
Published by John Wiley & Sons Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main St, Malden, MA 02148, USA
• Visual supports
• Scripting
• Social stories
• Modeling/video modeling
• TAII (e.g., SGD)

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