Behavior therapy is a long-standing, scientifically validated therapeutic option for eliciting desirable behaviors from those affected by autism and other psychological disorders. There is a great deal of evidence to support the efficacy of behavioral interventions, but there is often also a great deal of confusion regarding the most effective and the best types of behavioral therapy to use for the myriad behaviors and psychosocial challenges associated with autism.
What Is Behavior Therapy?
The basic premise of behavioral therapy stems from the Skinnerian theory of operant conditioning, which asserts that behavior is learned, and thus, can be unlearned or modified to comply with socially accepted norms. By evaluating and analyzing behaviors and subsequently offering a reward, also called a consequence, for those behaviors that are socially significant and desirable, maladaptive and/or undesirable behaviors can be reshaped or eliminated.
Four Types of Behavioral Therapies
Although Applied Behavioral Analysis (ABA) is among the most well-known and most widely utilized behavioral therapy options, there are other behavioral techniques that may be as beneficial or even more effective for achieving the desired goals. Because autism is a complex condition that manifests differently in each child, often the best outcomes for your child can be attained by utilizing a combination of varying techniques and strategies. Reviewing the most well-known and widely studied behavioral therapies may assist you in choosing the right interventions or combinations of therapies to help ensure your child's success.
1. Applied Behavioral Analysis (ABA)
Applied Behavioral Analysis is a highly effective method for mediating behavior across a variety of domains. The technique relies on the observation and analysis of the antecedents (A) of the targeted behavior (B) and the resultant consequence (C) of that behavior. Antecedents are sometimes referred to as triggers and are the first step in identifying the cause of a challenging or undesirable behavior.
This ABC methodology provides a foundation for clinicians to develop a highly specific and thorough treatment plan. Professionals will use this observed data, along with information provided by caregivers and loved ones, to develop a plan specific to your child's needs.
The Center for Autism and Related Disorders (CARD) indicates that Applied Behavioral Analysis techniques:
- Are effective for eliminating challenging behaviors such as stereotypies, hitting, biting or self-harm
- Can promote socially significant behaviors like reading, communication, engaging in eye contact, and social interaction
- Must be developed by a professional trained and certified by the Behavior Analyst Certification Board (BACB), but can be carried out by other, non-certified technicians under the professional's supervision
- Are time consuming and intense - usually implemented 40 or more hours per week, although in brief time spans
- Provide one-to-one interaction and learning, which is thought to be a highly effective component of the therapy
- Can be utilized by parents and other caregivers cooperatively within the treatment paradigm, although parents may need support and training to utilize effectively
2. Pivotal Response Treatment (PRT)
PRT is derived from Applied Behavioral Analysis and uses many of the same principals. However, the therapy strategies are more child-directed than observation-directed. The treatment focuses on pivotal behaviors like communication, social skills, academic skills, and the self-monitoring of behaviors. AutismSpeaks.org indicates that PRT techniques are:
- Effective for eliminating or redirecting challenging behaviors and promoting socially significant behaviors
- Can be implemented by trained psychologists, speech therapists, special education teachers, and parents
- Certifiable through The Koegel Autism Center, although certification is not required
- Offered in both structured and unstructured formats in six short segments that target language, play, and skill acquisition
- Implemented for about 25 hours each week
- A lifestyle as much as a therapy and are designed to complement family routines
3. Verbal Behavior Therapy (VB)
VB is another Skinnerian theory that has evolved from ABA that helps children understand how and why we use language. The focus is on using language rather than on the rote learning of words. Use of language to achieve a desired goal is rewarded, even if the word and/or gesture produced is not exact. According to AutismSpeaks.org, VB therapy:
- Is better suited to encouraging desired behaviors/language rather than eliminating undesired ones
- Encourages understanding language and communication in order to meet the child's needs and wants
- Can be implemented by trained psychologists, speech therapists, teachers, and parents
- Involves about 30 hours of scheduled therapy weekly but is likely to be more effective when reinforced in all the child's learning and living domains
- Uses shaping as a technique, which means that close approximations of the desired behaviors are rewarded and, as those are mastered, the demand for accuracy increases
4. Early Start Denver Model (ESDM)
ESDM uses behavioral principals to encourage developmental growth in language, cognition, social skills, and the achievement of other developmental milestones. While intensive, ESDM is meant to be enjoyable and can be implemented with very young children and infants. Emphasis is placed on capturing and holding attention through providing enjoyable and meaningful activities. AutismSpeaks.org indicates that ESDM therapy:
- Is designed to be enjoyable for the child and resembles play more than therapy (though it is therapeutic)
- Should be developed by trained professionals but can be utilized by all family members as well as other caregivers
- Can be more even more effective if begun in infancy or early childhood
- Focuses on capturing and maintaining attention with activities that teach social behaviors, communication, and other socially significant behaviors
Limits of Behavioral Therapies
Though behavior therapy is generally very effective, there are some limits to what it can achieve.
Consistency Is Key
Success with behavioral strategies, as with most therapies, depends on consistent and accurate implementation, which can be hard to achieve when a child is routinely exhibiting a constellation of disruptive behaviors. It is often very difficult to identify triggering events to challenging behaviors, and it can take extraordinary patience and a great deal of time to be successful. Persistence generally pays off, but it can be emotionally very trying for both parents and professionals.
Therapy Can Be Costly
Additionally, behavioral therapies can be very expensive. They take a lot of time and require a great deal of skill. Insurance does not always cover the cost, and trained professionals are not always readily available. It is generally unwise to try to implement intensive behavioral strategies without the aid and support of a trained professional, but sometimes parents are left with little recourse. Asking questions and utilizing the numerous resources available can help overwhelmed parents manage more effectively.
Behavioral and Speech Concerns
Some critics of behavioral therapies suggest that this approach may elicit robotic behavior and/or speech patterns. Since children who are affected by autism often exhibit these characteristics as part of the disorder, it would be extremely difficult to determine if behavioral therapy techniques are a contributing factor. Any concerns about these kinds of behaviors can be addressed with the care team and can likely be explained and/or mediated with careful examination and intervention.
The prior use of punishment as an acceptable form of behavior modification has also cast behavior therapy in a negative light. Punishment has been shown to be ineffective and is morally unjustified; qualified professionals avoid the use of punishment. Positive reinforcement is a far more effective approach and is the intervention of choice.
Choosing the Right Therapies for You and Your Child
All behavioral therapies share the same reward/consequence paradigm for changing behavior and learning new skills, and they may include some overlap in the way that they are implemented. Despite these similarities, however, children may respond more fully to one approach over another for any number of unknown reasons.
If your child is not developing as you expect, or if you believe that he or she may benefit from a combined approach, then pursuing additional therapies is an option to consider. Sharing your ideas and working cooperatively with the professionals who provide services for your child is a good way to explore the efficacy and practical application of other treatment approaches.