Early Autism Intervention: Yes, You Do Have Options

As I’ve traveled the country meeting early-intervention professionals and parents, I have come to realize a troubling paradox. We know from research that certain factors make autism intervention most helpful to very young children. But many specialists working with children don’t systematically use or recommend these approaches. The reasons are complex.

Researchers studying early intervention have identified four key features that make early-intervention treatments effective:

-Parents are highly involved, learning to be sensitive and responsive to their child’s emotional cues and behavior.

-Professionals individualize the treatment to address each child’s developmental profile.

-The treatment focuses on a broad range of issues rather than narrow targets.

-The treatment starts as early as possible after challenges are detected.

Too often, though, professionals recommend treatments that do not systematically value how important it is for mothers and fathers to be attuned to what their children are communicating through their behavior.

That’s because most agencies advocate only one autism treatment—just as most insurance plans cover only one autism intervention. That treatment is Applied Behavioral Analysis, known as ABA. Its focus is modifying behavior—that is, encouraging behaviors deemed desirable, and reducing those considered undesirable. If your child is currently receiving ABA and you are satisfied with your child’s progress and emotional health, the rest of this article may not apply to you.  If, on the other hand, you have questions, the rest of this article may explain why.

ABA is a therapy with a focus on measurable behaviors.  One aspect of ABA involves training children by offering rewards such as verbal praise or edible treats for complying. With the emphasis on behavioral compliance, ABA doesn’t necessarily encourage parents to become sensitive to a child’s emotional cues or stress levels prior to working on behaviors.

That’s probably why some parents share with me their discomfort with certain aspects of ABA. Many find it difficult to watch their toddler become upset when a therapist withholds a reward (such as a toy or edible treat) until the child complies with a directive.

One mother recounted her experience watching a therapist interact with her young son “Eric”, who loved to play with miniature toy farm animals. In an effort to teach the boy to request the toys verbally, the therapist held each animal in front of him, refusing to hand it over until Eric said its name aloud.

Watching her son reduced to tears was confusing to Eric’s mom, who didn’t feel comfortable carrying out the procedure with him on her own.

Sometimes, strict ABA programs do not teach parents how to sensitively respond to their child’s stress cues—things like fussing and crying—in the service of behavioral compliance. While the approach might help a child master isolated behaviors or skills, it’s focus is not on the emotional co-regulation between parent and toddler. Emotional co-regulation (helping the child feel calm and safe when distress is experienced) is an important part of attachment and bonding with one’s child.

This conflict can place parents in a bind. Should they follow the professional’s advice in the hope of ameliorating the child’s autism? Or should they follow their own intuition and attune to their child’s emotional needs?  It’s a dilemma, but newer blended approaches to treating autism in young children are available to address these concerns.

Parents should know that there are a growing number of research-based approaches in addition to ABA for treating autism in toddlers. Two examples, Autism LevelUP and DIR-Floortime, are both relationship-focused, non compliance-based strategies to support each child’s unique individual differences. Another is the SCERTS Model, which stands for social communication, emotional regulation, and transactional support. Each of these approaches recognizes the importance of the child’s sense of emotional regulation and feeling safe. These are essential to development and the psychological health of both parent and child.

If your child has been recently diagnosed with autism or if you are unsatisfied with your child’s current program, keep these helpful tips in mind:

There are options in autism treatment. Since professionals and educators may not apprise you of the many choices available, it’s essential to do your own research and pursue the approach that feels most suitable for your child and family. The free parent programs at the non-profit Profectum Foundation can help you understand what options are available and what are most appropriate for your child.

Trust your instincts. If a treatment method doesn’t feel right or makes your child uncomfortable, ask questions. Treatments for any developmental condition in infancy and toddlerhood should involve parents, and be both enjoyable and developmentally friendly.

Make joyful interactions a part of each day. Joy fuels learning, communication, and feeling safe. All three are necessary for your growing toddler, and should be no less part of the life of a child receiving early intervention than of any other child’s.

I write more about autism support in my new online course and book Beyond Behaviors, and join my newsletter below where I post helpful resources for parents and professionals.

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Thanks for this nice article! For an in-depth discussion, check out the three part article listed as ASQ 4, ASQ 5, ASQ 6 at http://barryprizant.com/resources/downloads/asq-articles/

Thank you so much for commenting, Barry. You have been setting the standard for family-centered practice for so many years and I love your new book, Uniquely Human!

I LOVE the Son-Rise program. It has been nothing short of a miracle for my family. I have three on the spectrum, and it has been a godsend for us. Going to their StartUp was the best thing I ever did. Truly.

That’s so wonderful, Luna. I’ve heard great things about the program from parents. I’m so glad you found it!

Full disclosure, I’m a BCBA-D that, obviously, has devoted her life to ABA. I think you are quite misinformed on some of your bold criticisms regarding ABA and are doing a huge disservice to parents seeking help. ABA includes incidental teaching, pivotal response training, natural environment training, floortime, TAG-teach, etc. which are all sensitive to the learner and to the parents. Further, good, proper discrete trial training (which is another approach used by ABA that I believe you just thought was the only thing ABA does) adjusts to the learner’s ability levels and provides appropriate prompts (assistance) to ensure that the child is successful. Your “non-example” lacks a bit of detail. If the child cannot (instead of will not) say the animal’s name and the therapist is requiring him to do so, then that is a poor approach and unfair to the learner. I completely agree. Yet, I’m sure I can find plenty of non-examples in the therapies you described. It is unfair bash an entire field, further a well-researched field, with one bad anecdotal example. Now, if the child in your example CAN say the name of each animal but is learning how to use functional communication as opposed to whines and tantrums to access the toy, then that is a good approach. How is that unlike parenting? When my child kicks and screams because I’m not giving into his demands (in my word it would be not wanting to change his diaper or brush his teeth), I’m providing a teaching opportunity – I’m not being cold, callus and aloof. Further, you imply that ABA is void of joy which is anything from the truth in my experience. My son sees his ABA therapist 3 days a week. Watching him quickly bounce up from the table, turn off his iPad or come in from digging holes in the backyard to open the door, greet his therapist and run up to the “classroom” is one of the highlights of my day. So, the take-home point is that while you can find a bad example with ABA, and I’ve encountered some as well unfortunately, give me 5 minutes and I can find plenty of bad examples of your alternative treatments. Maybe instead of making this an anti-ABA post, you spend more time detailing the treatments for which you are advocating. Because bashing the most effective evidence-based practice is a detriment to parents who are new to the world of autism. Side note: I’ll be impressed if you allow this post since it “diverges” a bit from the other comments.

Thank you so much for your respectful reply. I do have to applaud your graciousness given the direct criticism. I completely agree with you that any sort of treatment of any young learner needs to embody those four features you highlighted in the original post. Anything less of that would violate our own ethics as behavior analysts as Mika Jeff pointed out (with reference – thanks!).

Some great ABA programs that know include “happiness” measures with the client and social validity measures of the caregivers. An organization that I LOVE and works with clients more severe than I do, have “happy charts” where they track behaviors that can be classified as indicators of “happiness” of the client enjoying the therapy.

Another ABA agency who works with lower-functioning clients makes sure that the first skill taught is self-advocacy (accepted in many forms). If the client self-advocates to NOT engage in a particular program/skill by means of either “appropriate” or “inappropriate” means of advocacy, they don’t push it. After consecutive days of advocating to NOT do something, a change is made. That advocacy indicates that either 1) the skill is too hard and there is a component missing so it needs to be made easier or 2) it is not “fun” or “reinforcing” and needs to be change to get the acceptance from the client. They graph every work compliance or refusal and advocacy instances too.

In my center, working with clients higher on the spectrum, we track negative and positive statements to assess objective “feedback” about the client’s view of therapy. Further, we ensure a high ratio of reinforcer to behavior. When the percentage falls below 1:2, then we adjust expectations to ensure a high density is maintained. Not only do we see greater gains on the skills themselves, but we see higher positive statements. Further, our training, like many good ABA agencies, is extremely rigorous in teaching therapists how to be engaging, fun, sensitive, passionate, authentic, and reinforcing.

Just a little side-note. I believe the “applied” part of behavior analysis started at University of Washington, not UCLA. Ivar Lovass was at University of Washington and then traveled down south to UCLA where he was one of the first (if not THE first) to then extend ABA to autism. Maybe that is where you got the “birthplace” reference? Other ABA pioneers from the same University of Washington group include Sidney Bijou (who then went to Arizona and then UNR), Don Baer, Bill Hopkins, Todd Risley, James Sherman, and Montrose Wolf went to University of Kansas and founded the Journal of Applied Behavior Analysis.

Your agency sounds amazing, Kerri. I agree, all good therapies for tots should be engaging, fun, sensitive and authentic! There does seem to be a wide variation in how different agencies interpret programs for young children. What I am most interested in right now is the data on sympathetic nervous system distress (stress). Oftentimes, autistic children do not show in their facial expressions or words (even if vocal) when they are dysregulated. That’s one of the strengths I see in the DIR model where many different methods of measuring calm alertness are used,(for caregiver and child) prior to shifting behaviors in any direction. Anyway, this is a great discussion and I am open to hearing from folks as this is how we all help move the field forward! And yes, you are right, I forgot that Lovass did start his work at UW. I think that we in CA think of UCLA as where it really got momentum, and organizations like CARD were started but the UW can claim the roots of ABA.

Dear Kerri, I’m so glad you posted this comment. I want it here as I’m sure it speaks to many questions others have about this post. Thank you for commenting. I want to say that I have the utmost respect for all of us working in the field and devoting our lives to helping families. And I do have many children in my practice who, like your son, love their ABA work and specialists! That’s wonderful! And how it should be. Having said that, I have personal contact with many autistic individuals and parents from around the country. One of the more troubling things to me as a pediatric psychologist is that parents in some parts of the country are quite dissatisfied with their child’s ABA tx and feel they do not have a choice or are not told they have choices in autism treatment. I have colleagues at UCLA (the birthplace of ABA) who are producing high quality research showing that the best treatments for young children and toddlers contain the four qualities I mention in the post, and I agree with the research. I’m thinking that more than anything else, these four qualities should be a part of any program, regardless of what it’s called, and parents should know about them. Thank you again for commenting, Kerri.

Just as a clarification to one of the comments, ABA does not include floortime. They are two distinct treatment modalities. Floortime is a technique used by those trained in DIR by two organizations world wide: ICDL and the Profectum Foundation.

You are right – while floortime is not organically ABA, smack on some sensitive data collection and you have yourself some ABA! 😉 Pivotal response training embraced the child-led, naturalistic, teaching via playtime opportunities and just added some great data collection. The floortime method has reinforcers built into it naturally. Therefore, it seems like ABA, minus the strict adherence to data collection on every single thing (which we in ABA LOVE! – the more data, the better!).

ABA can be applied to many techniques since the DV is always behavior. Just add in a different data collection method/analysis through a different lens. ABA is added to surgeon training when refining their skill set (and it is NOT done with DTT – haha), it has been added to the training of athletes, physical therapy, occupational therapy, etc. Some of my favorite service providers are SLPs who deliver speech services while embracing APA principles. The “method” is specific to speech but they add some specific APA principles to enhance the technique. Singapore Math is an approach and curriculum for math learners – add some ABA to that and you have a really great pairing that is even more effective because it is functional, the data guides your decisions, and you can utilize principles of behavior when you get in an “oh no – what should I do now” moment.

So, that is why in my post, I included floortime. Yes, technically it is not originally ABA. But a few tweaks and it become PRT which is ABA.

While not a journal article, I found this comparing floortime, traditional ABA (really, DTT), and PRT: http://iancommunity.org/cs/simons_simplex_community/floortime_and_prt

Families first of all need to know their choices – all of them! I am the mom of two kids on the spectrum, who went back to school after they left for college to work with families impacted by autism. I understand the criticisms of some types of ABA, but ABA is really a broad-based field that offers many types of therapies. And any professional working with families should tell parents ALL of their options, including how different ABA programs work. I prefer evidence-based therapies that include play, parent attachment and an emphasis on communication, such as Dr. Milyko mentions, but also including Early Start Denver Model – which is a play based, parent-coached, attachment centered ABA therapy for young children and which has the highest rating on evidence research from the American Academy of Pediatrics. But I have met families who don’t want to work with me or that style of play-based intervention, and want a formal, table-based program in a formal setting. Families get to choose what is best. AND any therapist who tells you to ignore your child’s cues is not the therapist you should work with, no matter who they are or what therapy they follow! Listen, I tossed four BCBA’s out of my home because they did not respond well to my children, but then found two ABA therapists who used play and attachment and changed my kids lives. We need to empower families.

HI Claudia, Yes! That is the point exactly. Parents are the ones that need to make the decision on what approach is right for their child! The Early Start Denver Model is what I mention in the post. (ESDM) The four points are from a recent meta-analysis of 32 high quality studies. My article is meant to present parents of newly diagnosed infants and toddlers the latest evidence so they know they have choices, some of which have better evidence than the early ABA studies, and insurance is just slow to pick up on the research. Your families are lucky to have you there for them, and I wish all families had the support to not ignore stress cues and prioritize emotional regulation. Every neuroscientist I have discussed this with agrees. Thanks for your comments!

In response to the comments, I acknowledge that what I’m presenting is new information that can be unsettling. The four factors mentioned in the article are a result of a meta-analysis of many studies. Research is moving autism intervention forward, in a positive direction for clinical practice. As an infant mental health specialist, I feel that it is important that parents know about emotional attunement, which is the foundation of brain architecture. The umbrella of ABA is very large, and there is a wide variation of applications. Tracking antecedents and responses can be extremely useful, but we must consider the idea of physiological state as the intervening variable. This is a necessary conversation to have and will hopefully lead to more productive discussions and more parents asking questions and discovering a range of evidence based treatment choices when their infant or toddler is diagnosed.

What is the “new information” you feel you are presenting? If it’s new, you won’t be able to link it to data or anything scholarly because if so, it wouldn’t be new. But either way, you have yet to do so.

Kay, it’s the meta-analysis done by the MIND institute, one of the leading autism think tanks in the world. It’s referenced in my article as a hyperlink and the reason I wrote the article. It actually is from 2010 and since then many others have followed. The lab of Connie Kasari, Ph.D. at UCLA is another one pumping out research along the same lines. I think you will find her work, the work of Sally Rogers, Geraldine Dawson, and Stephen Porges all confirming this new way of looking at ASD treatment. They are all leading researchers in the field. Translating research into clinical practice in real time is a slow process. I write to help parents make the best decisions for their families, and I support many excellent ABA teams in my practice. Remember that this article discusses best practice for infants and toddlers, newly diagnosed.

The parts I could access never mentioned even ABA at all. Does the article actually state somewhere anything against using ABA? Based on the abstract and first few pages, the article has nothing to do with proving ABA is not the answer. Also, it says the purpose is something entirely unrelated to your “why ABA is bad” purpose as it isn’t even discussing cons of ABA or comparing it in general terms. You state yourself that the article doesn’t even discuss it when you remind us to “remember…” just now. It seems to be apples and oranges.

I work in the field of behavior analysis as a Program Managers Assistant and what I have learned from doing in-home therapy, therapy in the school setting and in the clinical setting is that everything about ABA keeps the parents concerns first. Since our learners can not come to us on their own, their parents or guardians bring their concerns to us and we work with the maladaptive behaviors that the parents feel are important. BCBA’s will complete their assessments to identify the function of the behaviors and then design a program that will target the behaviors of concern. The parents have to approve the intervention and it also has to be a program that will fit into their lifestyle. They need to be able to implement the program at home in between sessions. The four key features you mentioned are especially important when creating an intervention. Pairing with a child, making them feel safe, and making them feel like they are having fun when they are also actually learning is my job.
What I don’t understand is why withholding a “reward” for not completing a task is a “bad” thing. I have three children, 14, 12 and 2. My older children have daily chores to complete and they are working for a specific daily or weekly “reward”. If they do not complete their task, there is no reward. I think that is the real life lesson to learn. We don’t get rewarded for not completing tasks. My 2 year old knows that after he picks up his toys he can do some other fun activity or have a snack. We have greater consequences for not completing tasks like getting fired from our jobs. Understanding that we have to work for what we want is also another take away. It may be difficult for parents to watch their child get upset because they can not receive something they want but it is more of a disservice to the learner and the parent to reinforce a behavior that is undesired. Some parents can’t take their child to the supermarket because if they don’t get an item they want, the learner has a meltdown in the store. Our job is to help that parent be able to do things that we take for granted, like take our child to the supermarket, sit in a restaurant for dinner, or take them to school. We absolutely must be flexible in order to suit the needs of the parent and the child but as the professional we also need to be able guide the parent and show them evidence based treatments that work and show proven results. Ethically, we have a responsibility to do no harm, we are responsible to all that parties that are involved in the intervention, and to operate with the best interest of the client (Bailey & Burch, 2011). Informing parents of their options is a great thing but let’s be sure to not criticize a field keeping in mind a parent who may be new to the world of autism and may miss out because of something that we’ve said.

Reference:
Bailey, J. & Burch, M. (2011). Ethics for behavior analysis (2nd ed.). New York, NY: Routledge

Dear Mika,
Thank you for such a thoughtful comment. Helping children understand consequences is one of the best tools parents have!
It sounds like you are an incredible therapist. The example I gave in the article was to illustrate those times when a child and parent may not be ready to manage a behavioral approach. We then go to building a foundation with other strategies for the toddler and family from which to build the capacities to make behavioral changes. Thanks also for the reference.

Your article begins to describe ABA from the four key features. Treatment is most effective when parents are involved, which is a large part of the reason ABA is used in the home setting and why parents are strongly encouraged to continue following the program between intensive sessions. Each program has to be uniquely designed for the individual because the functions of problem behaviors differ and have to be explored, as well as what interventions are being responded to in which ways. ABA has recently become covered by insurances, and is the first major step towards helping individuals with autism, so it is unfair to say it is often the only option. It is also less restrictive than many other therapies, and can be applied in a variety of settings in a variety of individuals, which is why it is often one of the first methods tried. Of course early intervention is key, and I personally have worked in early intervention settings and with adults using ABA. Not every parent is willing to turn to professionals right away, which is unfortunate, but understandable for what I think are obvious reasons and as a parent, I’m sure you understand them as well. A large part of ABA is understand antecedents and tracking responsiveness and behavioral progress. A parent will generally be able to describe what happens before, during, and after a behavior occurs when asked those questions because they know their child best. That is valuable information in finding a starting place and tracking progress. No parent wants to see their child have a tantrum, so it would be natural to be uncomfortable when they have to watch their child whether it be planned ignoring or a particular response and wait until they earn their reward. Rewarding undesired behavior with a reward defeats the purpose of improving/changing a behavior, and might increase tantrums if that’s what’s being rewarded. So you’re correct in a sense and I believe you have heard concerns like that, but there is a situation around withholding a reward during negative behavior. I believe for ABA to work and programs to be maintained, parents have to understand the purpose. Not every ABA professional is a good one, we all know there are good and less-than-good individuals in every profession, so perhaps you’ve had experiences with those. I would hope that my clients and others, and I request this upon intake, are open about their concerns and tell me if they are uncomfortable or dislike something. I would much rather talk it out to see where the concern is coming from and how to work past it if possible, instead of wasting both of our time and inhibiting the individual’s progress. The function of the behavior is key. If the child has been crying or having tantrums because they are not getting their way or has the ability to do something yet refuses to (provided the details surrounding the situation that I do not have from your examples), the goal might be to increase independence and those might be target behaviors for change. Again, your discussion lacks specificity and important variables to determine whether or not ABA is being properly used and how the professional became involved to begin with. Many of the alternatives you noted include or can be used in combination with ABA techniques. You recognized this in at least one previous post. This article discourages parents without proper supporting details and evidence and attempts to eliminate one incredibly well-researched, data-driven type of therapy that has had great success in many individuals, which is truly unfair and contradicts your goal to provide options.

Hi Kay, I appreciate the feedback. The four key features came from a meta-analysis of over 30 high quality studies on the most effective results for infants and toddlers. Most neuroscientists including Stephen Porges, Dan Siegel and Tina Bryson all believe that the foundation of work with young ones must be physiological regulation, and attending to infant’s stress cues. In my work with families across the country, I am finding that ignoring stress cues is often part of ABA because the cues are coded as lack of compliance or unlearned behaviors. Unfortunately, that is not neurodevelopmentally informed as infants are wired for being soothed by their caregivers. I just want parents to know that if they feel uncomfortable with any type of therapy that they need to speak up and look to the latest evidence based approaches. Thanks for your comment!

You seem to talk in circles, and it’s really confusing and frustrating. Basically, you’re agreeing but also disagreeing based on “information” which is really just opinions and anecdotes you haven’t provided data to support. So, to pick a stance one way or another (what you say your article’s purpose is vs. what it actually serves to do) and provide some sort of data/actual evidence claiming ABA officially ignores stress cues (and perhaps to define what you consider a stress cue because it seems like that might be part of your misinformation) would be helpful. Your statements are very vague and lack the specificity necessary to form a proper argument, in my opinion and by the looks of it, many other readers’. Your tone shifts back and forth between previous posts, this post, and responses to comments, so I’m not even sure if you’re for or against, at this point.