What is ABA Therapy? An In-depth look

Applied behavior analysis (ABA) therapy is a type of therapy available to children with autism and other developmental needs. ABA is based on decades of research on the science of behavior and learning and is often considered the gold standard of care.

Through ABA therapy, children develop communication skills, learn self-advocacy, social skills, and more. Led by board-certified behavior analysts (BCBAs), each child’s treatment is individualized to fit their needs, abilities, and interests. There is no one size fits all approach to care.

History and progression of Applied Behavior Analysis

ABA is based on the science of behaviorism, as developed in the 1900s. By the 1960s, the first application of ABA for children with autism spectrum disorder began. Ivan Lovaas initiated the UCLA Young Autism Project, studying the effects of 40 hours weekly of direct ABA therapy. Lovaas, while influential in the field’s upbringing, is not without controversy. His approach to ABA therapy is often considered to be guided by a desire to make autistic children indistinguishable from their peers.

In today’s modern ABA, practitioners focus on teaching skills that improve a child’s quality of living, rather than aiming to “normalize” them. Goals are individualized to each child and emphasize skills that will help the child live independent and fulfilling lives.

Goals of ABA Therapy

The primary goal of ABA therapy is to help individuals improve their overall quality of life. This is done by teaching new skills and reducing behaviors that interfere with learning. The science of behavior guides the way behavior analysts implement skill development and behavior reduction plans. 

Communication goals

Communication delays are one component of autism diagnoses. Some children have no vocal-verbal communication abilities. Others can communicate, but require varying levels of support. ABA therapy meets children where they are by systematically building on their communication abilities. This may come in the form of vocal verbal speech or through augmentative and alternative communication (AAC) such as ASL, PECS, or a speech device.

Social skills goals

There are countless social skills that children and adults use daily, from simple greetings to a long back-and-forth conversation. While some people are naturally less social than others, developing basic social skills is highly beneficial.

Understanding emotions, nonverbal cues, and abstract language are all social and emotional skills that can help us relate to others and understand what others are communicating. Additionally, skills like active listening and conflict resolution can help when conflict arises at work, school, or in the community. ABA therapy addresses the social goals that are meaningful to each individual, considering cultural and familial social expectations.

Functional skill goals

Daily living skills such as washing hands, using the bathroom, and getting dressed can all be targeted within ABA therapy. A benefit to in-home ABA is the ability to work on these skills in the environment where they will most often be used.

Behavioral goals

In addition to goals related to building skills, behavioral goals are addressed in applied behavior analysis as well. Behaviors that interfere with a child’s learning or development are often targeted for reduction, in combination with teaching replacement behaviors.

ABA therapy encourages positive behavior change by identifying what the child is seeking by engaging in the behavior and helping them find other ways of meeting that need. For example, a young child with limited verbal skills screeches when they want something. A behavior plan might include teaching the child functional communication to get what they want. By teaching the child to request preferred items using pictures and reinforcing this, the screeching behavior is likely to decrease.  

ABA Locations

Applied behavior analysis is provided in many different locations. The most beneficial setting is child-dependent. Some children do best when they receive therapy in their home, with caregivers available and access to their favorite activities. Others thrive in a clinic or school setting where they can work on skills with peers.

Common locations of ABA sessions include

• In-home
• In a clinic setting
• In schools or daycares
• In the community (i.e. stores, restaurants, etc)

Procedures

Therapy usually involves a few different components. Procedures are likely to vary based on the provider but typically involve the following:

Diagnostic evaluation

While applied behavior analysis is not exclusively used with autistic children, an autism spectrum disorder diagnosis (ASD) is often required by funding sources including Medicaid and private health insurance. As such, the first step is typically a diagnostic evaluation. If your child has not yet been formally diagnosed, it is best to start there. 

Assessment

Prior to the start of ABA services, an assessment is conducted. This assessment is initiated by a board-certified behavior analyst (BCBA). The BCBA will conduct a record review, as well as meet with the child and caregivers to identify areas of need, current skills and strengths, and other information that will be helpful in the development of a treatment plan. From there, the BCBA writes a treatment plan that, among other things, outlines the goals that will be targeted during the treatment plan period.

Direct therapy and supervision

Once an assessment is completed and funding is secured, your child is ready to begin. Direct therapy sessions are typically conducted by a behavior technician or registered behavior technician (RBT). A BCBA will create the programming, train the technician, and provide ongoing supervision. The behavior analyst will analyze the goals and data progression each week. When modifications are needed, the BCBA will make the adjustments and continue analyzing the data. Ensuring that your child is progressing is a key component of applied behavior analysis.

Caregiver treatment guidance

This is sometimes referred to as parent training. Meaningful behavior change is a primary focus of applied behavior analysis. If a child can demonstrate skills with a therapist but does not demonstrate the same skills with a parent or caregiver, our job is not yet done. Teaching parents and caregivers to use behavioral strategies is necessary for generalization and long-term progress.

What does ABA look like?

There is no one way to “do ABA”. Each individual’s therapy session will look different. Sessions are likely to vary each day even for the same child. Some sessions may be play-based, with goals being addressed in the natural environment. Other goals might be worked on in a more structured setting like at a table. To help conceptualize what sessions might look like, let’s explore a few examples of ABA in action.

Teaching hand washing

Daily living skills like washing hands are often taught through a chaining procedure such as forward chaining. This would start by creating a task analysis, or a breakdown of the steps that encompass the skill. For example: Turn on water, wet hands, pump soap, scrub palms, scrub backs, rinse soap off, turn water off, dry hands. In a forward chaining procedure, the child would complete the first step(s) independently, followed by social praise to reinforce the skill. The remaining steps would be prompted through or demonstrated by the therapist. As the child masters each step, more steps are added for independent completion, until the child can demonstrate the skill without support.

Teaching requesting

Manding, or requesting, is an essential life skill. ABA programs commonly focus on requesting as one of the first areas to target. An ability to express your wants and needs is invaluable across all facets of life. Requesting items can be taught using words, pictures, signs, or devices, so even if your child is pre-verbal, they can learn to communicate their desires via other modes.

The ABA therapist would start by assessing your child’s current ability to request, otherwise known as their baseline. From there, they would systematically prompt your child to request using whichever mode they can be successful with (i.e. PECS, vocal words, etc). Reinforcement is provided as the item they requested, along with social praise. Over time, the prompts are faded out to allow for increased independence.

What can ABA help with?

As previously mentioned, ABA is not exclusive to autism. Due to the emphasis in the research on treating the symptoms of autism, many funding sources won’t authorize applied behavior analysis for other challenges. However, the scientific principles of behavior can be applied to many other diagnoses and facets of life.

Some other ways ABA can be used include:

• Organizational behavior management (OBM): This involves applying behavior analytic principles and contingency management techniques to workplace settings.
• Animal training: While the application of ABA with humans is much different than with animals, the behavioral principles are the same. Positive reinforcement is one of the main components.
• Classroom/school management: Many behavioral systems within schools are based on ABA principles.
• ADHD, Obsessive Compulsive Disorder (OCD), and other diagnoses: When exploring applied behavior analysis for other diagnoses, you may want to identify whether your insurance will cover it, and consider private pay or other arrangements if they do not. Additionally, because many ABA therapists primarily work with autistic children, you may want to seek a provider who has experience working with children with your child’s individual needs.
• Sports and athletic training: Principles of ABA can even be applied within sports settings. Studies have shown the use of reinforcement, feedback, stimulus training, and behavior chaining to be useful in developing skills such as tackling opponents in football.

Treatment Models

There are many different modalities of applied behavior analysis. Each is evidence-based and built on the principles of behavior. There is no one size fits all approach.

• Natural environment teaching (NET): This format of ABA is commonly used with toddlers and young children, though it can be applied to other age groups as well. NET uses a child’s motivation within their natural environment to teach communication, play, social skills, and more.
• Early intensive behavioral intervention (EIBI): An ABA treatment model focused on early intervention with young children, typically under the age of 5. This consists of 20-40 hours per week of direct therapy. The goal is to help the child develop skills at an early age to close the gap in communication and social deficits before a child enters school.
• Pivotal Response Treatment (PRT): A child-led and play-based therapeutic process that builds on communication and social skills, as well as self-management.
• Early Start Denver Model (ESDM): This approach is specific to children 12-48 months of age. Communicative and cognitive development are the areas of focus.
• Verbal Behavior Therapy: Focuses on teaching verbal behavior such as manding (requesting), tacting (labeling), and listener responding as the basis for early language development.

Costs and funding

According to the CDC, behavioral therapy for children with autism averages $50,000 per year. Thankfully, most states have laws requiring health plan coverage of medically necessary treatment such as ABA. The mandates vary in coverage amounts and limitations. You can check your state’s laws to learn what the requirements are in your area.

Where to start

ABA has a strong track record for improving the lives of children and their families. If you are interested in pursuing therapy for your child, consider the following steps.

1. Speak with a pediatrician: Usually, the first step is to consult your child’s pediatrician. You may need a referral or prescription for ABA, depending on the regulations in your area and the requirements of your insurance.
2. Contact your insurance: Check your policy guidelines to determine if ABA is a covered service and what out-of-pocket expenses you may expect.
3. Reach out to local ABA providers: Research companies in your area to get a feel for whether they might be a good fit for your family. Contact any you are interested in, to request additional information.

Initial questions you may want to ask include:

• Are you accepting new clients?
• How long is your waitlist, if there is one?
• Do you accept my insurance?

If you are in an area with minimal options for ABA, telehealth services would be worth exploring.

ABA therapy may just be the type of support your child needs to meet their full potential.

References

https://www.autismspeaks.org/blog/questions-and-answers-about-aba

Larsson EV, Wright S. O. Ivar Lovaas (1927–2010). Behav Anal. 2011 Spring;34(1):111–4. PMCID: PMC3089401.

Luiselli JK, Woods KE, Reed DD. Review of sports performance research with youth, collegiate, and elite athletes. J Appl Behav Anal. 2011 Winter;44(4):999-1002. doi: 10.1901/jaba.2011.44-999. PMID: 22219554; PMCID: PMC3251306.

Reichow B, Hume K, Barton EE, Boyd BA. Early intensive behavioral intervention (EIBI) for young children with autism spectrum disorders (ASD). Cochrane Database Syst Rev. 2018 May 9;5(5):CD009260. doi: 10.1002/14651858.CD009260.pub3. PMID: 29742275; PMCID: PMC6494600.

https://www.ncsl.org/research/health/autism-and-insurance-coverage-state-laws.aspx