FOI 24/25-0855
DOCUMENT 9
From: s22(1)(a)(ii) - irrelevant Aaron on behalf of TAPIB.Research Sent: Tuesday, 31 May 2022 2:41 PM To: TAPIB.Research Subject: RE: Research [SEC=OFFICIAL:Sensitive]
Hi again Kim
I’ve found this research paper from 2019: Research - ABA - Naomi - July 2019 - V2.docx
It contrasts ABA and positive behaviour support. Since it is pre-Autism CRC I don’t endorse the content. The references are mostly pretty old.
However, I was wondering if it’s the sort of thing you were after. Would you be happy for a review of this paper or are your questions significantly different from the questions posed in this paper? Note, that the cohort for this paper is adults.
Let me know if you’d like to discuss further or if I can help with the research request form.
All the best
Aaron
Research Officer, Enabling Services Technical Advisory Branch Operations and Support Division National Disability Insurance Agency
Phone: redacted Email: aaron. @ndis.gov.au
From: s22(1)(a)(ii) - irrelevant Aaron On Behalf Of TAT.RESEARCH Sent: Tuesday, 31 May 2022 9:43 AM To: Kim Cc: Stephanie Subject: RE: Research [SEC=OFFICIAL:Sensitive]
Hi Kim
Thanks for your time this morning. As I said, we can definitely look into the scope of ABA and distinguish it from behaviour support/management.
I have attached a research request form. Please complete as much info as you can and resave the file with a few words describing the research (eg. ABA and behaviour management research request). You can return it by reply to this address.
You’ll notice it says ‘DRAFT’ in the file name. We are trialling a new form and would love to get some feedback.
Hopefully it is pretty intuitive, but there are also some tips for filling it out after the form.
As you’re completing the form, if you can just note how you find it, if there are any issues or annoyances, that sort of thing.
Look forward to getting your request.
All the best
Aaron
Research Officer, Enabling Services Technical Advisory Branch Operations and Support Division National Disability Insurance Agency
Phone: redacted Email: aaron. @ndis.gov.au
1 Page 45 of 78
FOI 24/25-0855
From: Stephanie <Stephanie.
From: Kim <Kim.
Good Morning 😊,
I hope you are well.
I have been asked to compare the CRC Autism Research Paper against evidence we have about ABA programs.
Andrea has suggested that I reach out to you in relation to the above. Are you able to assist?
Thank you!
Kim
Administrative Appeals Tribunal Advisor / Senior Technical Advisor
Technical Advisory Branch
Operations & Support Division
National Disability Insurance Agency
E Kim.
The NDIA acknowledges the Traditional Custodians of Country throughout Australia and their continuing connection to land, sea and community. We pay our respects to them and their cultures and to Elders past, present and emerging.
For TAPS Advice Requests, please email:
2 Page 46 of 78
Research Request – Applied Behaviour Analysis
Any information or literature regarding implementation of ABA therapy for adults (with ASD and behaviours) as a recommended therapeutic intervention (Australian based preferably).
If ABA is not identified as an appropriate intervention, are there any other intensive therapies that are recommended?
(Participant Age: 22. Diagnoses: Cerebral Palsy, Autism Spectrum Disorder, Intellectual Impairment, self-harming behaviours, severe to profound communication disorder).
| Date | July 22, 2019 |
|---|---|
| Prepared for | Naomi redacted |
| Prepared by | Craig redacted |
Contents
- Overview & Research Base for Applied Behaviour Analysis (ABA) ……………………………………………. 2
- What is Applied Behaviour Analysis (ABA) ………………………………………………………………………….. 2
- Previous TAT advice on ABA for adults ………………………………………………………………………………. 2
- ABA with ASD adults as a recommended therapeutic intervention ………………………………………….. 3
- The Intellectual Disability Covary ……………………………………………………………………………………… 4
- Other Intensive Therapies for ASD Adults…………………………………………………………………………… 4
- Positive Behaviour Support (PBS) ………………………………………………………………………………….. 4
- Pharmacological Treatments ……………………………………………………………………………………….. 5
- Techniques derived from or used within ABA ………………………………………………………………….. 5
- Intervention Therapies & Individualized Needs……………………………………………………………………. 6
- Sources used in the compilation of this document ……………………………………………………………….. 8
Overview & Research Base for Applied Behaviour Analysis (ABA)
It is clear from reviewing the literature that ABA is the most widely used intervention therapy for those with ASD, but most of the literature refers to its application to children, with some open source literature suggesting it’s “useful” with adults as well.
There is also a running theme suggesting that studies regarding its application to adults needs more attention, and there are rising trends in recent open source type literature that its use may be harmful. Research indicates the need for ABA to be combined with other intervention therapies, as well as a “calling” for treatment plans to be based on the needs of the individual, rather than applying a “one size fits all” intervention therapy. There is also research asserting the potential significance of those with ASD and ID when taking intervention therapies into account. Other than open source popular narrative style literature, no Australian-based studies could be sourced.
From reviewing the literature there is an indication that there is a lack of research regarding implementation of ABA therapy for adults with ASD. “Based on available research, some recommendations for the treatment of challenging behaviours of adults (and children) with ASD include the use of functional assessment, side-effect monitoring of medications and behavioural methods whenever possible. Additionally, future research in this area needs to focus more on adults, as most current research has used child samples”. 1
What is Applied Behaviour Analysis (ABA)
“Applied Behaviour Analysis (ABA) is an approach to understanding and changing behaviour. It’s not a specific therapy itself, but a range of different strategies and techniques that can be used to teach people with autism spectrum disorder (ASD) new skills and reduce their difficult behaviour.
Applied Behaviour Analysis (ABA) teaching techniques can be used for all children with autism spectrum disorder (ASD) or children with other developmental disabilities.
The Applied Behaviour Analysis (ABA) approach and its techniques can be used to help children with autism spectrum disorder (ASD) improve their social skills, self-care skills, communication skills, play skills and ability to manage their own behaviour. It can also help reduce difficult behaviour like inattention, aggression and screaming.
Applied Behaviour Analysis (ABA) is based on learning theory, which comes from the field of behavioural psychology”. 2
Previous TAT advice on ABA for adults
A search of HPRM indicates one ABA advice relevant to adults, where the participant did not have any behaviours of concern, and his parents wanted him to access ABA. (ADV RN Applied Behaviour Analysis (ABA) therapy for an adult with autism – declined 2017/1759). The ABA request was not recommended as it was determined that it did not satisfy the NDIS reasonable and necessary criteria. It did not outline the participant’s expected therapy outcomes, or demonstrate the link to the goals in the participant’s NDIS Plan. The decision to not recommend the request was not associated with the credibility or efficacy issues with ABA as a practice in general.
1 S. Matson et al.,
Research Request - Applied Behaviour Analysis
Page 1 of 78
The Advisor for this case noted: “Autism Partnership Australia has provided a brief summary of research to support the ABA approach with adults – Advisor notes, evidence summaries are not available for ABA intervention approaches for adults, and while high quality individual studies can provide guidance for treatment decision making, the quality of the evidence in article summaries provided by Autism Partnership Australia would be considered as ‘low’ quality evidence by the National Health and Medical Research Council (NHMRC).”
The original requestor indicated that she was aware that sometimes the NDIS will fund ‘intensive’ supports for children, but was unable to find information about the same level of intensive supports being offered for adult participants.
Since the date of this advice: 22/12/2017, the Intensive and Super Intensive Practice Guidance has been developed.
ABA with ASD adults as a recommended therapeutic intervention
Literature regarding the implementation of ABA therapy for adults is limited, where most of the literature concentrates on its application with children.
“ASD is a particularly important risk factor for challenging behaviours such as aggression, tantrums, self-injury and pica. Adults with ASD have rarely been studied with respect to these problems. This is particularly disconcerting since there are far more adults than children with ASD. In addition, because of adults’ increased physical size and longer history of these problems, treating these behaviours effectively is important”. . . Based on available research, some recommendations for the treatment of challenging behaviours of adults (and children) with ASD include the use of functional assessment, side-effect monitoring of medications and behavioural methods whenever possible. Additionally, future research in this area needs to focus more on adults, as most current research has used child samples.
A Systematic Review of Psychosocial Interventions for Adults with ASD was sourced, where “an extensive literature search was conducted in order to locate published studies documenting interventions for adults with ASD including Applied Behaviour Analysis. This review identified a total of five studies that utilized ABA techniques. All of the included ABA studies were single case studies. All ABA studies sought to reduce the instances of an undesirable behaviour or increase the instances of a desirable behaviour. All ABA studies reported positive benefits of treatment, although the maintenance of this benefit varied between studies. Effect size was not reported for the ABA studies, as findings were based on a single subject”. 4
There is an indication in the literature that Positive Behaviour Support (PBS) is also a popular psychosocial intervention for those with ASD, and much of the literature on PBS takes into consideration its use with adults with ASD. PBS is an application of ABA and is behaviour analysis applied in support of people with challenging behaviour. PBS has led to new principles and procedures for the field of applied behaviour analysis.
“. . . efforts to establish PBS as a “brand name” and to disseminate PBS as a service delivery model have been enormously successful. Because PBS has largely been marketed as an approach that is
3 S. Matson et al.,
The Intellectual Disability Covary
There is research to indicate the potential significance of those with ASD and ID when taking intervention therapies into account.
A cohort study impresses the significance of ID amongst those with ASD indicating that “Autism and autism spectrum disorders make up one of the largest diagnostic subgroups within the entire population of individuals with intellectual disability. 6
A critical review indicated that “ID and autism spectrum disorders covary at very high rates. Similarly, greater severity of one of these two disorders appears to have effects on the other disorder on a host of factors. A good deal of research has appeared on the topic with respect to nosology, prevalence, adaptive functioning, challenging behaviours, and comorbid psychopathology”.7
Other Intensive Therapies for ASD Adults
Positive Behaviour Support (PBS) appears to be the most “discussed” intervention therapy aside of ABA, and there is a running theme in the literature indicating the need for alternatives to ABA and its application to adults with ASD:
“Because many of the problems associated with ASD in childhood persist into and often intensify in adulthood, psychosocial interventions that target communication, social interaction, and flexibility of thinking and behavior, similar to those reported in reviews of the child ASD literature . . ., may prove efficacious in the treatment of adults with ASD. Certainly, companies that cater to families and to agencies that serve adults with autism market a plethora of costly intervention programs and self-help books that promise to help this group of people in any number of ways. However, empirical evidence supporting their effectiveness is often not available”.
Positive Behaviour Support (PBS)
Positive Behaviour Support (PBS) is an individualised and comprehensive approach that parents and carers use to teach and encourage children to behave in appropriate ways. The approach makes difficult behaviour unnecessary by removing the things that trigger, encourage or reward that behaviour. It also teaches children alternative, more appropriate behaviour to replace the difficult behaviour. 9
A high quality peer literature review showed that “PBS was effective with both severe and high-rate behaviour problems, was cost-effective, used a methodology that was easily trained and widely disseminated, and worked in institutional settings in which the most difficult problems are thought to
Research Request - Applied Behaviour Analysis
be, as well as in the community. The major implication of this review is that practitioners may be obligated to use PBS when faced with the need to develop a plan of support given the ethical principle of using the least restrictive method consistent with the right to effective treatment.
While PBS is ABA in support of people with challenging behaviour, PBS has itself led to new principles and procedures for the field of applied behaviour analysis. . . Although the ethical practice of ABA requires the least restrictive method be used, referrals for PBS services often involve people whose problems are serious and for whom a punitive approach had been tried and failed”. 10
Pharmacological Treatments
Pharmacological treatments is mentioned within the literature as an adjunct to intervention therapy where challenging behaviours are very severe as can be the case in adults with ASD.
. . . because of adults’ increased physical size and longer history of these problems, treating these behaviours effectively is important. Psychological methods, particularly applied behaviour analysis, and pharmacotherapy have been the most frequently addressed treatments for challenging behaviours associated with ASD in the research literature. In many cases, challenging behaviours have clear environmental antecedents. In these cases, behavioural interventions, such as applied behaviour analysis, should be used to reduce the behaviours. When environmental factors cannot be identified or when challenging behaviours are very severe, pharmacological treatments may be necessary in combination with behavioural interventions. 11
Techniques derived from or used within ABA
Following are other intervention techniques for those with ASD where no reference for application to adults could be found. All of the techniques are derived or used within ABA:
Discrete Trial Training (DTT)
DTT is not a therapy in itself, but a teaching technique used in some autism spectrum disorder (ASD) therapies. It is based on ABA theory. It involves breaking skills down to their most basic parts and teaching those skills to children, step by step. All achievements are rewarded, which encourages children to learn. Sometimes called Discrete Trial Teaching, DTT is often used as part of a broad ABA-based approach.
Source: Raising Children Network (Australia) Limited
Incidental teaching
Incidental teaching is not a therapy in itself, but a naturalistic teaching technique used in some therapies, particularly ABA programs. When teachers (or parents) are using incidental teaching, they use naturally occurring opportunities for learning, like playtime, to develop children’s skills. And they reinforce children’s attempts to behave in a desired way the closer the children get to the desired behaviour.
Source: Raising Children Network (Australia) Limited
Pivotal Response Treatment (PRT)
PRT is not a therapy in itself. It’s a set of teaching techniques used in children’s everyday environments. PRT is based on the principles of ABA. It focuses on four key or ‘pivotal’ areas of children’s development, with the aim of helping children develop more complex skills and behaviour including social and communication skills. ASD include PRT techniques as part of their approach, particularly ABA-based programs. Other common names for PRT include Pivotal Response
10 Lavigna, G and Willis, T,
Intervention and the Natural Language Paradigm.
Picture Exchange Communication System (PECS)
PECS is a way for people with ASD to communicate without relying on speech. To communicate, people use cards with pictures, symbols, words or photographs that represent tasks, actions or objects. ASD can use the PECS. There’s no age limit, but research has focused on children. This therapy is also suitable for anyone who has a problem with spoken language, including people with developmental delay and traumatic brain injury. PECS was developed in the United States in 1985, as part of the Delaware Autism Program. It’s based on the principles of ABA.
Intervention Therapies & Individualized Needs
There is a rising trend in the narrative type literature indicating that intervention therapies should be based on individualized needs of the person and that there is no one size fits all approach.
For many years, and still today, many researchers have focused on comparing one treatment to another treatment, or a treatment versus “usual care” in the community. In my own opinion, the idea of trying to figure out which specific treatment is “best” is a dead issue. We need to stop trying to figure out a one-size-fits-all treatment and focus on a technology that allows us to be open minded about what effective and evidence-based treatments are available and how to best fit the combination of these treatments to the specific features and needs of the individual.
Controversies surrounding the ABA
In the narrative type literature, there is a rising trend emanating from the US and Canada, suggesting that ABA can be harmful to children with ASD.
“ABA is considered by many researchers and clinicians to be the most effective evidence-based therapeutic approach demonstrated thus far for children with autism . . . There are, however, some controversies surrounding the ABA approach. Early ABA practice (in the 1980’s and early 1990’s) included the use of aversive techniques such as yelling at or restraining a child. Most ABA practitioners no longer consider aversive techniques to be acceptable, and the current ABA approach is equally effective without these techniques”.
“Applied behavioral analysis is the most widely used therapy for autism, but some people say its drills and routines are cruel, and its aims misguided. . . ABA has a predatory approach to parents, says Ari Ne’eman, president of the Autistic Self Advocacy Network and a prominent leader in the neurodiversity movement. The message is that “if you don’t work with an ABA provider, your child has no hope. . . Whether ABA is helpful or harmful has become a highly contentious topic — such a flashpoint that few people who aren’t already advocates are willing to speak about it publicly . . .”
12 American Psychology Association, Individualized Treatments Are Future of Autism Therapies, According to Psychologist: Seven questions for Laura Schreibman, PhD, [website], 2012, https://www.apa.org/news/press/releases/2012/04/autism-therapies, (accessed 17 July 2019)
13 L. Pullen, PhD,
Research Request - Applied Behaviour Analysis
“While use of aversive reinforcement is generally gone, there is still a complaint that ABA therapy, which can involve a lot of repetition, is tough on the children, and the skills they learn don’t necessarily generalize to other situations”. 15
15 Child Mind Institute, The Controversy Around ABA: Why some autism parents and advocates find fault with the therapy, [website ], hhttps://childmind.org/article/controversy-around-applied-behavior-analysis, (accessed July 19 2019)
Research Request - Applied Behaviour Analysis Page 53 of 78
Reference List
| American Psychology Association, “Individualized Treatments Are Future of Autism Therapies, According to Psychologist: Seven questions for Laura Schreibman, PhD”, [website], 2012, https://www.apa.org/news/press/releases/2012/04/autism-therapies, (accessed 17 July 2019) | Website Article |
|---|---|
| Child Mind Institute, The Controversy Around ABA: Why some autism parents and advocates find fault with the therapy, [website], https://childmind.org/article/controversy-around-applied-behavior-analysis, (accessed July 19 2019) | Website Article |
| E. Bradley et al., |