This article was originally an ASAT feature. It comes to us from Alan Schnee, PhD, BCBA-D. To learn more about ASAT, please visit their website at www.asatonline.org. You can also sign up for ASAT’s free newsletter, Science in Autism Treatment, and like them on Facebook!

I’ve been teaching children with ASD for many years. Often my attempts to teach WH questions are unsuccessful. While children learn some rote responses, once I attempt to generalize to new situations, children seem to confuse questions. For example, if I ask a child, “Where did you eat?” the child might say, “Pizza.” Do you have any idea why the child gets confused, and do you have any suggestions to address this?

Answered by Alan Schnee, PhD, BCBA-D
Nexus Autism Intervention Services, Cherry Hill, NJ

This is an excellent question. Children with autism often confuse WH questions. They often respond to a given WH question as though a different question were asked. For example, a child may answer a, “what” question when a, “where” question is asked. It is sometimes suggested that children confuse WH questions because of an auditory “discrimination problem,” which is to say that children don’t differentiate the words. However, it’s been our experience that children who can match words in verbal imitation still confuse WH questions. So, what else can it be? It is important to consider that children simply don’t know what these terms mean. To say that someone knows the meaning of a word is based on behavioral criteria and what a word means is determined by convention. To say that someone doesn’t know what a word means is to say they do not use and respond to it according to the rules for its use (Hacker 2013, p. 115).

So, what does this mean for us? It means we need to consider what it would take for children to learn how to use and respond to given words. This means that children need to learn what a word is used for. It means that we need to consider how to engineer intervention so that children learn compatible words to which target words are linked. It means that we need to contrive circumstances, situations and transactions in which progressive mastery is achieved within a normative structure and ultimately, it means that much more goes into teaching children to answer WH questions than relying exclusively on rote responses to long lists of arbitrary WH questions.

Considerations for Preparing Children to Answer “Where” Questions

When we ask a, “where” question, our uncertainty concerns locations and destinations. Thus, to ask, “where” is to ask, “At which place or from which place.” To such questions we expect answers that reference some place in conjunction with a preposition (e.g., from the kitchen, on the table). Therefore, in order to be able to answer rudimentary, “where” questions, children need to learn the names of things (couch, table, rooms, stores, etc.) and prepositions (close, to, at, near, from, under, on, beside, etc.) used in relation to a place, as well as non-specific spatial referents (here, there) – which requires that children are able to follow/use a point, eye gaze, or other gestures.

When we begin teaching children to answer, “where” questions, it is common to start with basic ‘table-top’ spatial relations. For example, when we arrange on a table, a red block on a cup and a green block next to a cup we might ask, “Where is the red block?” (Frazier, 2018; Leaf & McEachin,1999; Lund & Schnee, 2018; Taylor & McDonough, 1996). Once these rudimentary relations are in place, children will need to go places and report on where they went, came from, and where they are going (declaring destinations). They will need to be stationed in places (self-positioned) and report where they are so to be able to learn and link destinations and locations using “at,” “to,” ”from,” “in,” etc.

Additionally, it is important to keep in mind that uses of, “where’’ extend beyond spatial relations. Thus, to ask, “Where are you?” can in one sense be used to ask for an opinion, or in another to ask about progress within a process (e.g., “I’m in the middle.” “I’m at the beginning.”) or to ask about a state of attention (e.g., “Sorry, I was in ‘In La-La Land”). These examples also illustrate that responses to, “where” questions may rely on metaphoric or idiomatic uses of prepositional terms, as when we say we are standing, “on line,” even though we are not standing on anything.

It should also be pointed out, when answering, “where” questions, pragmatic considerations come into play (Lund, 2015). So, when asked, “Where are my keys?” answering factually that, “They are in New Jersey” may not be particularly helpful if both the person asking and the person answering are in the same kitchen in New Jersey. However, if the same question were asked in Chicago, that same answer would be suitable. Similarly, history needs to be taken into account. Thus, if I’m in Chicago, and my wife is in our kitchen in New Jersey and she asks where the keys are and I say “In the can.” then our shared history makes my response both understandable and useful. However, the same answer would not be suitable to a new guest staying in our house who asks the same question. Given these considerations, hopefully this section illustrates some different ways the word, “where” is used, what it would take for children to respond appropriately to, “where” questions and how learning to memorize responses from item lists cannot prepare children for such a task.

Considerations for Preparing Children to Answer “Why” Questions

When teaching children to answer, “why” questions, there is also a tendency to teach children rote responses from item lists. This section should clarify why doing so will not advance children’s abilities in this area. In language, to ask a, “why” question is to say, “Give me a reason.” In the, “why” language game, any number of reasons could be offered to a question. For example, to the question, “Why did you wash your hands?” there is an indeterminate number of appropriate answers:

• “Mommy told me to.”
• “My M&M melted in my hand.”
• “We always wash before prayer.”
• “I hate when my hands are dirty.”

The possible reasons follow from an unpredictable number of factors and situations. One may state their reason/s for why they did or didn’t do something, say or didn’t say something, felt one way or another, believed, desired, needed or hoped for something, etc. based on whim, preference, need, demands, fear, shame, misinformation, new information, etc.

Before we begin to teach children to answer or use, “why,” it is important that other abilities are in place. Children need to learn to do things, make things, go places, give and get things, look for things, etc. The use of, “why” and responding to, “why” questions often hangs on circumstances which often fall out of activity. Once children are doing things, they should be able to (at a minimum) report on what they are doing, using, or where they are going. We find it especially helpful, before we introduce, “why” questions, that children learn to use tools (for making art, eating, building things, cleaning or cooking, etc.) and to ask for things they need.

One early strategy we employ for introducing, “why” questions is ‘piggybacking’ off of interrupted chains; sabotaging an activity so that it can’t be completed without the child seeking assistance in some way. For example, once a child can make things using tools (e.g., in order to make a face, a child can use tape or some other tool to attach googly eyes to the paper), we make sure the tool is unavailable. This assumes the child has learned to ask for things she needs in order to complete a task. Thus, when a needed tool is unavailable (by design) and when the child asks for it, we can ask the child, “Why do you need it?” to which we prompt the child to say something like, “I need it to attach the eyes to the paper.” Working like this has the added benefit of providing a platform for introducing or strengthening concepts such as, in this case, “attach.” Additionally, arranging things in this way is important for teaching ‘functions’ since in such scenarios, children are actually learning to use the tools they need, to ask for them when it’s appropriate and to explain why they need them, all in real time. We do this as opposed to teaching children to answer rote questions out of context. Working this way addresses several dimensions of skill acquisition simultaneously and illustrates considerations related to careful planning for the construction of ‘advanced’ abilities.

Considerations for Preparing Children to Answer “When” Questions

The concept, “when” denotes time. To ask a, “when” question is to ask, “At which time?” Answers to when questions take the form, “When x,” such as to the question, “When are you coming for dinner?” to which the answer has the form, “When I finish work.” The answers also take a form combined with prepositions so the answers could look like, “At 5:00,” “On Tuesday,” or, “In a minute.” Thus, the word, “when” is bound up with prepositions (before, after, on, in, at, next, etc.) in relation to standard time markers such as calendar events (days, weeks, months, years, holidays, seasons), or clocked times (minutes, hours, seconds). “When” is also linked to commonly used, non-specific time related concepts, “soon,” “later,” and, “now.”

We need to be mindful of the fact that prepositional terms (before, after, on, in, at, next, etc.) used to mark time are also used to refer to spatial relations. Teaching children to use them when learning to answer one WH question (e.g., when) will not likely translate or ‘generalize’ to use in others (e.g., where). For example, saying, “In a minute.” and, “In the cup.” each require different teaching arrangements if children are to learn their varied applications.

Finally, it is important to point out that the concept, “when” is bound up with rule following. While ‘when rules’ may be based on standard time markers, it is probably more common in everyday linguistic practice that they do not. Rather, rules for some future event are often linked to arbitrary, idiosyncratic events such as, “You start running when the gun sounds.” or, “You can watch your video when Mommy comes home.” Hopefully, pointing out these considerations illustrates that more needs to be considered than teaching children only rote responses if they are to be able to answer, “when” questions.

Considerations for Preparing Children to Answer “Who” Questions

The concept, “who” is a pronoun that is used to stand in for persons or personified objects such as dolls or play animals. When a “who” question is asked, we are asking, “Which person?” Thus, “who” is linked to persons’ names, personal pronouns (I, you, my, your, me, my, mine, we, they, us, his, her, etc.) and to things personified.

We often introduce the concept, “who” by asking children to identify persons in pictures (e.g., “Who is it?”). Once this basic ability is in place, we will combine, “who” questions with other concepts:

1. Actions (Who is acting?)
2. Prepositions (Who is under, on, in etc.?)
3. Possession (Who has ‘x’ ?)
4. Gender (Who is that boy?)
5. Role (Who is that teacher?)
6. Attribute (Who is that tall person?)

The difficulty in responding to, “who” questions increases significantly as the requirement to answer them involves using other subject pronouns (e.g., I, you, he, she, we, they) or objective pronouns (e.g., me, him, her, us, them).

Considerations for Preparing Children to Answer “What” Questions

When we ask, “what,” we expect answers that point to things, actions, events/experiences. Early in intervention, children learn to answer, “what” questions related to colors, shapes, functions, actions, size, naming objects, etc. (Frazier, 2018, Leaf & McEachin,1999: Lund & Schnee, 2018; Taylor & McDonough,1996). Learning to respond to, “what” questions as addressed in introductory manuals also includes learning to answer rudimentary ‘what-action’ questions such as, “What are you doing?” or “What did you do?” This offers a good start, but more than naming current or past actions is required when considering ‘what-action’ questions. For example, when teaching progressive actions, children’s answers are based on the intended outcome (Lund & Schnee, 2018). So, if children are building a tower with colored blocks, the response to the question, “What are you doing?” is not, “Putting the red square on top of the green cylinder.” but “Building a tower.” Therefore, teaching children to state their intentions related to future activities also needs to be considered.

There will be times when it is important to teach children to memorize responses to factually based WH questions, as long as there are good reasons for doing so. Very often, memorized responses will be needed for the construction of other abilities. For example, being able to answer questions like, “What color is an apple?” and “What are the parts of a car?” will later be needed for teaching children to make comparisons (similarities and differences). Beyond this, children will need to learn to answer non-factual, “what” questions for which memorized answers are not possible. Such questions include queries about emotional, sensory or perceptual experiences, as well as questions involving psychological predicates, “thinking,” “believing,” “wishing,” etc.

Solidifying Rules for Answering WH Questions

Once basic abilities are in place concerning WH terms, a next step is vital and requires that we systematically intersperse WH terms. When doing so, children will have to pay close attention, as there are more moving parts, more possible moves since several ‘games’ are rotated in and out of play, in quick succession. Interspersing terms should help solidify the rules for responding to these terms (when/time, where/place, what/ things-actions, who/persons, why/reasons), at least at a rudimentary level. Below is a example, modified from Lund and Schnee, (2018, p.107) which intersperses, “who” in the context of, “where” and, “what.”

In this exercise, two-to-three (or more) persons are situated around a room or are seated in a circle. Familiar objects are placed around the room and questions are randomized. For example:(a) “What is over there?”

(b) “Where is the [object]?”

(c) “Where is [person]?” followed by, “What does (person) have?”

(d) “Who has the [object]?” followed by, “Where is she?”

(e) Add the question: “Where is the [object]?” when someone is holding the object. The child should answer, “[person] has [it]” rather than, “over there.” Randomize questions about objects in someone’s possession (“[person] has it”) and not in someone’s possession (“over there”).

Introducing Use Of WH Terms

When children learn to appropriately use and respond to WH terms, we can say with greater confidence that children possess the concepts, “where,” “why,” “when,” “who” and “what”. Introductory exercises for learning to ask some WH questions can be found in Leaf and McEachin,1999; Lund and Schnee, 2018; Taylor and McDonough,1996. To enhance learning beyond what is found in introductory manuals, we take advantage of ‘everyday occurrences’ and manipulate their frequencies in order to increase practice opportunities. For example, we can, as we begin to leave a room, grab our coats or briefcases and make statements that invite a question by saying something like, “See ya later.” or, “I’m going out.” Such statements pull for the question, “Where are you going?” An example of how we begin to get asking, “when” off the ground, might involve telling a child that they will have access to an activity in the near future by saying something like, “We’re going to the park later.” Such statements naturally pull for a, ‘when’ question. A variety of strategies can be then employed to help children situate the upcoming event in relation to a current activity. If we simply pay attention to situations that call for the use of these terms and find ways to systematically arrange for their occurrences at greater frequencies, children will have corresponding opportunities to learn to ask appropriate questions given those situations. In these ways, we can do much to help children learn to use these terms appropriately and to strengthen their overall abilities concerning them.

A Final Note

I hope I was able to shed light on some of what is involved in preparing children to be able to answer WH questions. I further hope that I was able to illustrate why it is important to move beyond the practice of only teaching children to memorize responses to WH questions and why doing so may help children learn to answer them masterfully. While there are times it is useful to teach children to memorize responses (for constructional considerations), the general practice of teaching children to memorize responses does not inform what we, as teachers, need to consider as we begin to support children in developing abilities related to answering or asking WH questions. Teaching children to memorize responses to different WH questions ignores considerations involving compatibilities and combinatorial possibilities between terms and the complicated engineering required to link them in use. It ignores the different uses of some of the terms. It ignores the need to ensure that prerequisite abilities are reliably demonstrated and ready for uploading into the many possible situations, circumstances or transactions in which they may be put to use. Ultimately, it ignores the considerations that will prepare children to participate in the practices, activities, actions and reactions in characteristic contexts in which the rule-governed use of these words is integrated (Hacker, 1999). There is much to consider (not all of which could possibly be accounted for here) as intervention is developed toward progressive mastery of these terms within a normative structure.

References

Frazier, T. J. (2018). ABBLLS-R skill acquisition program manual set. DRL Books.

Hacker, P. M. S. (1999). Wittgenstein (the great philosophers series). Rutledge.

Leaf, R. B., & McEachin, J. (1999). A work in progress: Behavior management strategies and curriculum for intensive behavioral treatment of autism. DRL Books.

Lund, S. K. (2015). Untitled. Unpublished manuscript.

Lund, S. K., & Schnee, A. (2018). Early intervention for children with ASD: Considerations. Infinity.

Taylor B. A., & McDonough, K. A. (1996). Selecting teaching programs. In C. Maurice, G. Green, & S. C. Luce (Eds.), Behavioral intervention for young children with autism: A manual for parents and professionals. (pp. 63–177). Pro Ed.

Citation for this article

Schnee, A. (2020). Clinical corner: What goes into teaching WH questions?, Science in Autism Treatment, 17(5).

About The Author 

Alan Schnee, Ph.D., BCBA-D consults domestically and internationally to families, agencies and schools that are committed to providing Early Intensive Behavior Intervention. He has been involved in autism intervention for almost 30 years. He is the founder of Nexus Language Builders, a center-based, full-day, intensive learning program for school age children, formally in Verona, NJ. Dr. Schnee is the co-author of the book, Early Intervention for Children with ASD: Considerations and he continues to lecture and write on topics related to the intricacies of teaching language and the conceptual foundations of language. He has also written on topics concerning the enhancement of memory, attention, executive function, social awareness and social acuity in children with ASD. Dr. Schnee earned a Ph.D. in clinical psychology from Georgia State University and has been board certified as a behavior analyst, doctoral level since 2010. He is based in New Jersey.

This month’s ASAT feature comes to us from Kate McKenna, MEd, MSEd, MS, BCBA, Association for Science in Autism Treatment, and Brittany Hardie, PT, DPT, Melmark. To learn more about ASAT, please visit their website at www.asatonline.org. You can also sign up for ASAT’s free newsletter, Science in Autism Treatment, and like them on Facebook!

This is part of the Description of the Treatment Team series.

History

As detailed in Moffat (2003), physical therapy has a long history in the United States and the profession has evolved over time in response to multiple major historical and medical events. The involvement of physical therapists in responding to polio epidemics that erupted sporadically from the 1800’s to the 1950’s, when the development of the Salk polio vaccine led to control of the disease, resulted in a gradual expansion of the field and innovations in the use of physical therapy to treat severe mobility deficits. Bed rest with long-term splinting and casts which immobilized limbs and the spine was an early accepted treatment for polio. This treatment led to muscle atrophy which then required physical therapy in an attempt to regain mobility. Later interventions for polio included exercise, massages, heat and light therapy, hydrotherapy, and the use of assistive and adaptive equipment. Physical therapists were at the forefront of responding to those who survived polio and needed support to cope with the effects of the disease.

The two World Wars also heavily impacted development and innovations in physical therapy. During World War I, physical therapists, known also as reconstruction aides, worked with doctors, providing exercise programs, hydrotherapy, and massage therapy to wounded soldiers. The number of amputations in World War II led to the funding of the Artificial Limb Program, a 25-year effort to enhance prosthetic services and to support veterans in their use. As with treating polio survivors, physical therapists were instrumental in staffing the programs that developed new technology and intervention strategies for amputees.

Professional associations for physical therapists were first founded in the 1920’s with the American College of Physical Therapy (ACPT), which was later known as the American Congress of Physical Therapy. The American Women’s Physical Therapeutic Association (AWPTA) held its first meeting in 1921 to establish professional and scientific standards for physical therapists, who at that time were predominantly women. The name of this organization was changed to the American Physiotherapy Association (APA) in 1922. The goals of the APA included establishing standards for education and scientific research, promoting the practice of physical therapy, providing a central registry of trained therapists, and providing current information on physical therapy to members of the medical profession and the public. By the late 1930’s, physical therapy was considered a medical specialty. In 1946, the APA changed its name to the American Physical Therapy Association. Also in 1946, the Hill Burton Act was passed. The bill established an effort to build a nation-wide system of hospitals across the United States. Six thousand nine hundred hospitals were built by 1975. As medical specialists, physical therapists continued to work alongside doctors, nurses, and hospital staff to provide critical care in the area of movement rehabilitation.

When the Education of All Handicapped Children Act, now known as the Individuals with Disabilities Education Act, was passed in 1975, physical therapy became a related service offered to students in educational systems. Today, physical therapy is a commonly mandated related service provided to students with autism and other developmental disabilities.

Education

Graduate-level coursework for physical therapists (PTs) includes courses in anatomy, physiology, kinesiology, neuroscience, pharmacology, ethics/values, behavioral sciences, biomechanics, and clinical reasoning. All certified and licensed PTs hold a clinical Doctor of Physical Therapy (DPT) if they enter the field after 2016. This involves obtaining a bachelor’s degree in a related field, such as health science or biology, and then continuing with a 3-year DPT program at an accredited college or university. Prospective PTs then must pass the National Physical Therapy Exam (NPTE®) for physical therapists, which is based on a comprehensive practice analysis to assess critical knowledge, skills, and abilities of physical therapists. Additionally, PTs are licensed to practice in the state or jurisdiction where they work.

A Physical Therapy Assistant (PTA) practices with an associate’s degree from an accredited physical therapy program, which is a combination of coursework and clinical training. PTAs must also pass the National Physical Therapy Exam (NPTE®) for physical therapist assistants. PTAs practice under the supervision of a DPT and the parameters of that supervision may vary by state. The Continuing Education (CE) requirements needed to maintain both levels of licensure also vary by state.

Guiding Documents

PTs are guided in their practice by the American Physical Therapy Association Code of Ethics for the Physical Therapist which consists of eight principles that speak to protecting the dignity of consumers, acting with integrity, the use of evidence-based practices, committing to ongoing professional development, and engaging in ethical business and organizational practices. PTAs practice under the APTA Standards of Ethical Conduct for the Physical Therapist Assistant, which describes the principles as they apply to PTAs, and outlines the limit of their practice under the supervision of a PT.

All members of APTA have access to Clinical Practice Guidelines which are based on systematic reviews of the research evidence. The Guidelines are also intended to maintain consistency in care decisions. To aid PTs in staying current with trends and the latest refinements in their practice, the APTA website provides links for its members through Article Search with full-text access to research and articles from more than 5,000 clinical and academic publications.

Professional Organizations

The mission of the Federation of State Boards of Physical Therapy (FSBPT) is to “protect the public by providing service and leadership that promote safe and competent physical therapy practice.” The process of establishing the FSBPT began in the early 80’s in an effort to form a professional organization to oversee the continuing development and administration of the National Physical Therapy Exam (NPTE), which at that time was owned by the APTA. In 1987, 22 states committed to joining the newly formed FSBPT and in 1989 the ownership of the NPTE transferred from the APTA to the FSBPT. In addition to the certification exam, the FSBPT works to safeguard consumers by identifying and promoting effective regulation in physical therapy, ensuring safe and competent physical therapy service delivery, and providing educational programs and materials to its members and the public.

The American Physical Therapy Association (APTA) is the professional organization of physical therapists in the United States. Its mission is to build a community that advances the profession of physical therapy to improve the health of society. APTA’s stated vision for the profession of physical therapy is to transform society by optimizing movement to improve the human experience. Currently, APTA offers board-certification in 10 specialty areas of physical therapy:

• Cardiovascular and Pulmonary
• Clinical Electrophysiology
• Geriatrics
• Neurology
• Oncology
• Orthopedics
• Pediatrics
• Sports
• Women’s Health
• Wound Management.

PTJ: Physical Therapy & Rehabilitation Journal, the official journal of APTA, is an international journal publishing peer-reviewed articles for both clinicians and researchers on topics related to physical therapy and rehabilitation. The Journal of Orthopaedic & Sports Physical Therapy (JOSPT®, Inc.) is the monthly publication of the Academy of Orthopaedic Physical Therapy and the American Academy of Sports Physical Therapy of the American Physical Therapy Association. The journal publishes content for members of the health care community with the goal of advancing musculoskeletal and sports-related practice globally. The organization has developed partnerships with 32 orthopedic, manual therapy, and sports organizations in 23 countries worldwide. Physical and Occupational Therapy in Pediatrics (POTP) delivers information to physical therapists involved in the developmental and physical rehabilitation of infants, children, and youth who practice in hospitals, rehabilitation centers, schools, and health and human services agencies. The Journal of Physical Therapy Science is the official journal of the Society of Physical Therapy Science. This monthly publication seeks to accelerate the progress of physical therapy research in Asia. The American Journal of Physical Medicine & Rehabilitation is a publication of the Association of Academic Physiatrists (AAP). Physical Medicine and Rehabilitation (PM&R), also known as physiatry, is a subspecialty of medicine related to the diagnosis, treatment, and rehabilitation of people with a disability who are disabled by disease, disorder, or injury due to conditions with the nervous and musculoskeletal systems. Physical and Occupational Therapy in Geriatrics seeks to publish a balance of articles related to research and clinical practice across the healthcare continuum when working with older clients.

Scope of Practice

PTs practice in a variety of settings including schools, hospitals, homes, and community settings. They provide early intervention, short-term remedial, or long-term care related to improving movement and mobility. Additionally, physical therapists practice in mental and behavioral health settings such as rehab centers. Others conduct research to improve the knowledge and treatments used in practice. Physical therapists also serve as advocates for both their profession and the clients they serve by promoting legislation related to insurance reimbursement, workplace safety, and ensuring that those that would benefit from physical therapy have access to it. In their professional practice, PTs are not solely concerned with client welfare. Their scope of practice also includes contributing to public health services and legislation to maintain and improve the health of the general public.

Many individuals with autism experience delays in gross motor development and function. Early delays in sitting upright, crawling, and walking, for example, can result in a cascade effect in which children lose opportunities to learn by interacting with and exploring their environment. Deficits in postural strength, coordination, and stamina hinder one’s ability to engage in such activities as riding a bike, playing kickball, or swimming. Physical therapists, sometimes working in the area of adaptive physical education, may target functional mobility, body and safety awareness, the ease of transitioning from one activity to another, and increased motor imitation skills. Across the lifespan, individuals on the spectrum may need to learn to step off and, on a curb, enter and exit public transportation, or use an escalator. Physical therapists work with people on the spectrum to build the motor planning skills, strength, and stamina required to access their environment, navigate stairs, move through hallways, sidewalks, and outdoor spaces safely and with as much independence as possible.

Physical therapists diagnose and treat dysfunction and difficulties with movement. In their practice, PTs seek to restore and maintain the optimal physical function and well-being of their clients. Their intensive training provides them a distinct body of knowledge of how the body functions in motion that PTs use to support their clients’ purposeful, precise, and efficient movement across the life span.

References

Becoming a PTA. American Physical Therapy Association. https://www.apta.org/your-career/careers-in-physical-therapy/becoming-a-pta

Brody, L. T., & Hall, C. M. (2005). Therapeutic exercise: Moving toward function, 2nd Edition. Lippincott Williams and Wilkins.

Direct access in practice. American Physical Therapy Association.
https://www.apta.org/your-practice/practice-models-and-settings/direct-access

Directory of physical therapy programs. (n.d.). Commission on Accreditation in Physical Therapy Education. https://www.capteonline.org/

Learn physical therapy basics. (n.d.). The Federation of State Boards of Physical Therapy. https://www.fsbpt.org/Secondary-Pages/The-Public/Learn-Physical-Therapy-Basics

Moffat, M. (2003). The history of physical therapy practice in the United States. Journal of Physical Therapy Education 17(3), 15-25. The History of Physical Therapy Practice in the United States: Journal of Physical Therapy Education (lww.com)

Physical therapist’s scope of practice. (2017, September 13). American Physical Therapy Association. https://www.apta.org/your-practice/scope-of-practice

Specialist certification. American Physical Therapy Association.https://www.apta.org/your-career/career-advancement/specialist-certification

Standards of practice for physical therapy. (2020, August 12). American Physical Therapy Association. Standards of Practice for Physical Therapy | APTA

Citation for this article:

McKenna, K., & Hardie, B. (2023). Focus on the treatment team: Physical therapy. Science in Autism Treatment, 20(10).

Other Articles in this Series

1. Description of the Treatment Team
2. Focus on the Treatment Team: Speech-Language Therapy
3. Focus on the Treatment Team: Occupational Therapy
4. Focus on the Treatment Team: Applied Behavior Analysis

About the Authors

Kate McKenna, MEd, MSEd, MS, BCBA, LBA, received a Masters in Child Study from the Eliot-Pearson Department of Child Study at Tufts University, a Masters in Special Education from Pace University, and a Masters in ABA from Hunter College.  In addition to New York state certifications in general and special education from Birth to Grade 2 and Grades 1-6, she holds a New York State Annotated Certification in Severe/Multiple Disabilities. Kate is currently completing a Masters degree in Children’s Literature at Eastern Michigan University.  She was an extern at the Association for Science in Autism Treatment before joining the Board of Directors in 2020.

Brittany Hardie PT, DPT, is a physical therapist at Melmark, PA and serves on team for individuals with autism from ages 5 to 22 years. She received her Bachelor’s degree in Health Science from Eastern Nazarene College and a Doctor of Physical Therapy from the University Of Maryland School Of Medicine, Baltimore.  Dr. Hardie is licensed in Pennsylvania and New Jersey and has been practicing for 9 years.  She is also a certified clinical instructor.  Dr. Hardie strives to achieve the best outcomes related to mobility and movement for the individuals she serves and enjoys the abundant opportunities to collaborate with colleagues from other disciplines afford by her current position.

By Alan Schnee, Ph.D, BCBA-D.

Roughly 34% of the 50 most common words used in English are pronouns. Yet, with few exceptions, children on the spectrum struggle to use them.

Why is it so difficult for children to learn? One likely reason is that the use of pronouns is contextually determined. Learning to use them requires vigilant tracking across shifting speakers and listeners (you, I, they, he, she, Ralph, etc.), and shifting events. It is a complex process requiring acute attention to who is in possession of what, changes in possession, attention to who did or said what,  and who did or said what to whom, etc. If our goal is to assist in teaching children to use and respond appropriately to pronouns, where should we begin?

First, we need to clear up some confusion Pronouns are words that stand in for nouns. Though it is commonly said that we ‘tact pronouns’, saying this lacks sense. Pronouns are not objects or events or properties of an object or event. They are simply words. They exist in language and are used within a normative linguistic practice. There are no pronouns in the world and thus it makes no sense to say we “tact” them.

When it comes to learning pronouns, children need to learn the complicated things we do when we use them; under which circumstances we use which one(s) and the ‘linguistic acrobatics’ required for fluent use. So, for example, when a child is told to, “Go tell Mommy that you need her keys, they need to be able to formulate the response,  “Mommy, I want your keys.”

Teaching pronouns needs to be taken slowly and requires considerable practice (repetition). It requires getting rudiments in place before tackling more complex arrangements and objectives.

Early pronoun exercises quickly become far more complex as ‘transformations’ are required. For example, a standard “My/Your program”, (teacher says, “Touch my nose or touch your nose”) requires learning a straightforward discrimination. However, once a follow-up question such as “Whose nose is this?”, is presented, things become very difficult for children since they need to switch their response such that what was just “my” becomes “your” and visa versa. Instruction in the use of pronouns requires meticulous execution of discrete trials. Additionally, echoic prompting is contra-indicated. Children will need to learn to respond to a “say” instruction. The exercise below, taken from Lund and Schnee (2018) illustrates just how complicated teaching use of pronouns can be.

Nominal Pronouns (4): Shifting speakers

(This sample exercise follows more basic ‘pronoun’ exercises.)

Purpose

To teach the child to use nominative pronouns “I” and “You”, combined with proper names

Set Up

Three or more persons required

Have the child hold an object (e.g. cup)  and you and an assistant each hold different objects. You and the assistant   rotate asking.

Procedure

Step one: You and assistant rotate asking, “Who has the  “X” (e.g. cup) vs “Who has “Y” (e.g. ball), “Who has “Z” (e.g. spoon). When you ask questions regarding the assistant, the child refers to her by name.  When you are the spectator and the assistant is asking questions ,the child will refer to you by your proper name and the assistant as “you”.  Of course the child always refers to themselves as “I” and when you are asking, the child refers to “you” as “you”.

Step two: You or assistant ask the child “What do you have” , “What do I have”, “What does (person/proper name have?)”.

Prompt correct responses according to who is in possession of each object, i.e, I have the X or You have Y, ‘Proper name’ (Sally) has Z . This is more difficult than step one because if requires transforming the pronoun. Make sure to change what each of you is holding so that the child will not memorize responses.

Considerations

This exercise is not only matter of answering questions. It entails personal deixis; the right answer depends on who is asking. The primary goal is to teach the child to say “you” when the speaker asks the child what the speaker is holding, to say “I” when the speakers asks about what the child is holding and to use a proper name when the child is asked about what any other person is holding (if that person is not the speaker). This discrimination requires considerable practice.

If the child struggles with these arrangements, segment instruction into smaller ‘switched’ sequences as described in step 3 of Assigning Pronouns to Pictures of Persons 1.

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About the Author

Alan Schnee, Ph.D, BCBA-D. offers consultations to families, schools, and other organizations wishing to enhance their programs so that their children derive maximum benefit from services. His unique approach increases learning efficiencies, broadens the scope, depth, and breadth of your program, provides clarity for children and teachers and imparts sensible purpose and directions to teams and parents.

By Sam Blanco, PhD, LBA, BCBA

Creating opportunities for interactions is key when working with any child, but it is especially important when working with children with autism. ABA often gets a bad rap for being staid or leaving a kid stuck at a table doing discrete trials for hours on end. In reality, it should be neither! While I do discrete trials in my practice, my biggest priority is always focused on increasing learning opportunities by taking advantage of the child’s natural motivations. This typically means leaving the table, so I alternate between discrete trials and lots of teaching through games and activities. Here are a few of my favorites:

Toss & Talk

For this activity, I usually use a large ball, a soft ring, or something else the child can toss. I name a category, and we take turns tossing the ball (or other item) and naming an item from that category. The game can be easily modified for whatever you’re working on: counting, skip counting, or even vocal imitation. I like the game because it’s simple, it provide a back-and-forth that is similar to a conversation, and it can easily be modified to include peers, siblings, or parents. This is particularly great if your learner likes throwing balls, but I’ve also modified it to push a train back and forth or take turns hopping towards one another.

Play Dough Snake

This game is one I saw a preschool teacher use years ago and have had great success with. In this game, I simply create a snake out of play dough. I make a large opening for the snake’s mouth, then roll up little balls of dough that will be “food.” I tell the child that we are going to pretend the play dough is food. I have a silly snake voice, and I tell the child “I’m so hungry. Do you have something I can eat?” The child picks up a piece of the rolled-up play dough, tells me what kind of food it is, and then feeds it to the snake. I pretend to love it, and the little ball of play dough becomes incorporated into the snake’s play dough body (which is great, because the more “food” the snake eats the bigger it gets.)

I can expand the game to have the snake dislike certain foods or tell the child he is too full. On several occasions, the learner has asked if they can be the snake, which is fantastic! This is another great game for peer play, sibling play, and modeling.

Pete’s A Pizza/You’re A Pizza

One of my favorite books for young learners is Pete’s A Pizza by William Steig. In this book, it’s a rainy day and Pete’s parents entertain him by pretending they are making him into a pizza: they roll up the “dough,” toss him in the air, add toppings, etc.

This is another game I saw a preschool teacher using during play time, and one I’ve used with many, many students. Sometimes I read the book beforehand, but if my learner’s level of comprehension or attention span is not appropriate for the book, I can just introduce it as a standalone game. I say, “It’s time to make a pizza!” Then, we get into the fun part of rolling the learner around, tossing him on a couch or mat, etc. This can generate a lot of language, work on sequencing, and provide a lot of opportunity for requesting activities.

Anything with a Parachute

My parachute is one of my best purchases of all time. I use it often and it allows me to play a wide range of games. Besides just having the learner lay on the floor and have the parachute float down onto his/her body, it is a highly motivating toy for a range of activities. Many of my learners love just pulling that large item out of its small bag. I’ve already written about three games I frequently play with the parachute. You can read that here.

Songs

Repeating rhymes and songs with motions that your learner loves can provide anticipation of an activity that may increase eye contact and manding. One of my favorites is shown in a video here. While this video is shown with toddlers, I’ve used it with kids up to 6 or 7 years old. Similar activities might include Going on a Bear Hunt; Heads, Shoulders, Knees, and Toes; and Animal Action.

It’s important to note that none of these activities is beloved by every learner I encounter. The idea is to have a range of possible activities to learn which ones are motivating to your learner, then use those to create opportunities for language and interaction.

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About the Author

Sam is an ABA provider for school-aged students in Brooklyn, New York. Working in education for over 15 years with students with Autism Spectrum Disorders and other developmental delays, Sam utilizes strategies for achieving a multitude of academic, behavior, and social goals. She is also an assistant professor in the ABA program at The Sage Colleges and the Senior Clinical Strategist at Encore Support Services. You can read more of Sam’s posts for Different Roads To Learning when you click here!

This month’s ASAT feature comes to us from Kate McKenna, MEd, MSEd, MS, BCBA, and Kristina Gasiewski, MEd, MOTR/L, BCBA, Association for Science in Autism Treatment. To learn more about ASAT, please visit their website at www.asatonline.org. You can also sign up for ASAT’s free newsletter, Science in Autism Treatment, and like them on Facebook!

This is part of the Description of the Treatment Team series.

History

Behavior analysis is the science founded on the belief that behavior should be the primary focus of scientific study (Cooper et al., 2020). It is both a discipline and a practice. The philosophy on which the science of behavior analysis rests is radical behaviorism, the supposition that all human behavior including thoughts and feelings can be studied and understood. The experimental analysis of behavior, associated with B.F. Skinner, emphasizes scientifically studying the relationship between behavior and the variables in the environment that control it.

Applied behavior analysis (ABA), as the name implies, is the application of behavioral principles to real-world problems with the goal of effecting lasting and positive change in socially important behavior (Baer et al., 1968; Fennell & Dillenburger, 2014). At the heart of applied behavior analysis is the belief that behavior can be studied and understood, and that this understanding can guide how teachers and clinicians respond or intervene. Since behavior is shaped by the individual’s interactions with people, objects, and events in the environment, we can arrange the environment to affect the change we want to see. In other words, by studying the antecedents (what happens before a behavior occurs) and consequences (the response from the environment after the behavior occurs), it is possible to ascertain the purpose or function of behavior (the reason the behavior happened). That information allows us to arrange the environment to result in behavior that is beneficial to the individual engaging in the behavior and the broader society, and that will respond effectively to social problems faced by a community (Cooper, 2020).

Although ABA is often used as a catch-all descriptor of current techniques used in the treatment of autism, it has a history unrelated to autism treatment dating back to the turn of the 20^th century. Classical conditioning of behavior was described by Ivan Pavlov in his famous set of experiments with dogs. Learning theory developed by Edward Thorndike held that learning results in the consequences of our behavior. John Watson is known as the “father of behaviorism.” He posited that behavior is the result of observable and recordable environmental events. This was a sea change in the investigation of learning and the science of behavior. At that time psychology studied mental processes, the conscious, and the unconscious. Introspection was used as the method of investigating the purpose of behavior. In contrast, Watson suggested direct observation of environmental stimuli and the responses that result.

In the 1920s B.F. Skinner advanced the idea that understanding our behavior is essential to understanding ourselves. He wrote extensively on the application of behavioral principles to social issues such as education, the law, economics, and self-control. Skinner thought it possible to create living environments that benefit all individuals and societies. He believed that all behavior, including thinking and feeling emotions, which he called “private events,” could be described and observed. Skinner called this radical behaviorism.

The seven dimensions of ABA were first outlined in a seminal article published in the Journal of Applied Behavior Analysis (Baer et al, 1968). ABA is applied in that it focuses on creating socially significant change that is meaningful for those involved. ABA is behavioral in that it objectively defines and measures target behavior in such a way that it is possible for anyone to observe and record instances of the behavior. The dimension of being analytic refers to the ability to predict and control a target behavior. This functional relationship allows the clinician or teacher to create environmental conditions in which a target behavior is more or less likely to occur. In meeting this dimension, in both research and clinical practice, BCBAs are guided by their professional code of ethics to ensure that target behavior and goals are truly beneficial to the learner.

Any description of scientific research, treatment plan, or educational program must be written with sufficient clarity and detail so that another researcher can replicate the study to substantiate reported results or that a clinician unfamiliar with the student can step in based on the information provided. This is the definition of technological. Related to this dimension is the call that ABA-based interventions and research be conceptually systematic, that is that it be grounded in the principles and tenets of applied behavioral analysis. The final two dimensions of ABA, effectiveness and generality, speak to the goal of lasting significant change that benefits all stakeholders. Target behavior, interventions, and research must be socially valid and matched to the individual’s skills, needs, and their interactions in their environment. For an intervention to be effective it must fit within the daily lives of the people involved. Methods used to support change should be practical, not overly costly, and designed to be as convenient as possible to those who will live with them long term. Interventions should be generally applicable. That is, they should be functional in a variety of environments, apply to a range of behaviors, and have sustainable and maintainable effects. The ability to generalize newly acquired knowledge and skills in new environments, with similar but not identical materials, and with a variety of people is critical to the success of ABA-based interventions.

The principles of ABA have been found beneficial in the fields of addiction and substance abuse (Silverman et al., 2011), gambling (Weatherly & Flannery, 2008), eating disorders (Peterson et al, 2022), forensic analysis (Ruben, 2019), gerontology (Burgio & Burgio, 1986), and other mental health specialties (Harvey et al., 2009). These broad applications speak to the strength of ABA-based interventions in addressing many diverse challenges.

As with any scientific field, new discoveries and knowledge prompt discussion and influence how principles are put into practice. Standards of ethical and effective practice have evolved since the 1960’s. The concepts of assent and consent are at the heart of the effective practice of ABA. Assent is agreeing or approving of something after considering it carefully. Consent involves granting permission for something to happen or agreeing to do something. Both assent and consent are important in the interactions during teaching sessions between the providers and learners as well as the balance in the relationships between providers, individuals, and family members. One key aspect of learning is genuine engagement in the activity and with the materials. The goal is for the individual to be “happy, relaxed, and engaged,” willingly participating with no visible signs of discomfort (Hanley, 2021; Parenti & Rothman, 2023).

Education

Behavior analytic professionals include Board Certified Behavior Analysts (BCBA®), Board Certified Assistant Behavior Analysts (BCaBA®), and Registered Behavior Technicians (RBT®). Certification programs are accredited by the National Commission for Certifying Agencies (NCCA), the accreditation body of the Institute for Credentialing Excellence (ICE). While there are BCBAs across the world, as of January 1, 2023, the BACB made changes to their international focus and currently accepts certification applications from individuals who reside in the United States (US), Canada, Australia, and the United Kingdom (UK). The International Behavior Analysis Organization (IBAO) certifies applied behavior analysts worldwide and offers two certifications, the International Behavior Analyst (IBA) and the International Behavior Therapist (IBT).

A BCBA is a graduate-level certification in behavior analysis. BCBA practitioners can practice with either a Master’s or Doctoral Degree. The Board-Certified Behavior Analyst-Doctoral (BCBA-D ®) is a BCBA with a doctorate degree. It is not a separate certification, and functions within the same capacity as a BCBA.

There are different pathways to sit for the Behavior Analyst Certification Board (BACB) exam. First, behavior-analytic coursework can be attained through either an Association for Behavior Analysis International (ABAI) accredited or recognized behavior analysis degree program, or a Verified Course Sequence. Master’s or higher behavior analysis degree programs that have been accredited or recognized by ABAI have met these standards for the curriculum, faculty, and resources, among others. Accredited programs may be found on ABAI’s Accredited Programs web page. A Verified Course Sequence is a set of courses that have been verified by ABAI as having met the BACB’s behavior-analytic coursework requirements. Verified Course Sequences may be located using ABAI’s Verified Course Sequence Directory. Some typical courses of study include the study of ethics for behavioral practice, functional behavioral assessment and analysis, experimental analysis of behavior, experimental design and research, evidence-based instructional methods, methodologies of behavior change, science and philosophy of ABA, verbal behavior, collaboration, and supervision.

Once coursework has been started, candidates can begin to accrue fieldwork hours. There are two means of satisfying hours including supervised fieldwork (2,000 hours) or concentrated supervised fieldwork (1,500 hours). Trainees may accrue hours in a single category or may combine the two types, supervised and concentrated, to meet the fieldwork requirements. Hours accumulated each month must be at least 20 hours but cannot exceed 130 hours. Additionally, fieldwork hours include independent hours (supervisor not present) and supervised hours (supervisor present). There are specific requirements for each type of fieldwork that specify the number of required contacts with the supervisor, observations, and percentages for supervision per supervisory period, individual supervision, and unrestricted activities.

Once the above requirements are met, a candidate may take the BCBA examination, which is composed of 185 multiple-choice questions. Once certified, a BCBA is to obtain 32 continuing education units (CEUs) within each 2-year recertification cycle including 4 CEUs in ethics and 3 CEUs in supervision (for supervisors). For specifics and the most up-to-date information on obtaining the BCBA credential, please refer to the BCBA handbook.

BCaBAs have an undergraduate-level certification in behavior analysis and must be supervised by BCBAs. Like the BCBA, there are different eligibility pathways. Each pathway requires a degree, behavior-analytic content, supervised fieldwork (1,300 Supervised fieldwork or 1,000 concentrated supervised fieldwork) and passing the BCaBA certification examination. The BCaBA examination comprises 160 multiple-choice questions. Once certified, BCaBAs must obtain 20 CEUs per 2-year recertification cycle including 4 CEUs in ethics and 3 CEUs in supervision (for supervisors). For specifics and the most up-to-date information on obtaining the BCaBA credential, please refer to the BCaBA handbook.

RBTs are paraprofessionals certified in behavior analysis. They assist in delivering behavior-analytic services and practice under close supervision from a BCBA. RBTs have a high school-level education or equivalent. Once a candidate completes a 40-hour training and Competency Assessment, and has a supervisor on record with the BACB, they are eligible to sit for the RBT certification exam. The RBT examination comprises 85 multiple-choice questions. Renewal of this certification is every year and includes an RBT Renewal Competency Assessment. For specifics and the most up-to-date information on obtaining the RBT credential, please refer to the RBT handbook.

Standards of Practice and Guiding Documents

Knowledge requirements, ethical standards, and disciplinary procedures in the practice of behavior analysis are established and monitored by the Behavior Analyst Certification Board, Inc.^® (BACB^®). The BCBA Task List (5^th ed.) outlines the minimum knowledge and skills necessary for effective practice and serves as the foundation for the questions on the BCBA examination for prospective BCBAs and BCaBAs. The Ethics Code for Behavior Analysts guides the professional activities of BCBAs and BCaBAs by outlining core principles involved in ethical decision-making that apply to behavior analysts’ professional activities during in person service delivery, in written reports, and in interactions via phone, email, text message, and video conferencing. Core principles, which guide all aspects of the work of behavior analysts and form the basis of ethical decision-making, are to benefit others; treat others with compassion, dignity, and respect; behave with integrity; and ensure our own competence (practice only within our scope of competence). Separate documents cover ethical behavior and scope of practice limitations for RBTs.

Professional Organizations

Established in 1998, the Behavior Analyst Certification Board, Inc.^® (BACB^®) is the professional organization that certifies BCBAs, BCaBAs, and RBTs. The BACB’s stated mission is to “protect consumers of behavior-analytic services by systematically establishing, promoting, and disseminating professional standards of practice.” The BACB establishes practice standards, develops certification examinations, and oversees continuing education of certificants. It has also created ethics requirements and a system of oversight for each of the three certification options and for those in a supervisory role in their practice.

The Association for Behavior Analysis International (ABAI), established in 1974, is the primary professional organization for behavior analysts. Through its special interest groups, affiliated chapters, international conferences and journals, ABAI fulfills its mission of supporting and educating professionals interested in the philosophy, science, application, and teaching of behavior analysis. ABAI has 40 special interest groups which speaks to the breadth of application ABA has to society. ABAI publishes six peer-reviewed journals. Perspectives on Behavior Science is the official publication of ABAI and publishes articles on theoretical, experimental, and applied topics in behavior analysis. Since 1937, The Psychological Record has published empirical and conceptual articles related to behavior analysis, behavior science, and behavior theory. Behavior Analysis in Practice provides information on best practices on topics relevant to service delivery to service providers, school personnel, and supervisors. Education and the Treatment of Children presents articles written in a practitioner-friendly style for individuals working with children and youth at risk for or experiencing emotional and behavior challenges, and who are practicing in schools or treatment centers. The stated mission of The Analysis of Verbal Behavior is to “support the dissemination of innovative empirical research, theoretical conceptualizations, and real-world applications of the behavioral science of language.” Affiliated with the Behaviorists for Social Responsibility special interest group, Behavior and Social Issues is an interdisciplinary journal that publishes articles that analyze the social behavior of people to better understand and address significant social problems.

The Society for the Experimental Analysis of Behavior (SEAB) was founded in 1957 to promote the advancement of the science of experimental analysis of behavior and to disseminate information about behavior analysis. To that end, the Society publishes the Journal of the Experimental Analysis of Behavior and the Journal of Applied Behavior Analysis. The Journal of the Experimental Analysis of Behavior publishes articles primarily related to research on individual organisms. The Journal of Applied Behavior Analysis, first published in 1968, publishes research on the use of behavior analytic principles to issues and problems of social importance.

Scope of Practice and Approach to Intervention

Applied Behavior Analysis is a scientific approach for identifying environmental factors that reliably influence socially significant behavior. Socially significant behaviors are those that enhance and improve people’s lives. These behaviors can include social, language, academic, daily living, self-care, vocational, and/or recreation and leisure behaviors. The overarching goal is to change behavior, either by increasing or decreasing the occurrence, and is achieved through various principles of behavior (e.g., reinforcement, punishment, stimulus control, environmental contingencies; Cooper, et al., 2020). BCBA’s use ABA-based programs and strategies in a variety of other fields, such as gerontology, brain injury rehabilitation, addiction, both general and special education, organization behavior management, public health, and sports psychology.

BCBAs are guided by ABA principles. Behavioral methods are utilized to measure behavior, teach functional skills, and evaluate progress. Common services may include but are not limited to, conducting behavioral assessments, analyzing data, writing behavior-analytic treatment plans, training others to implement components of treatment plans, and direct implementation of treatment plans (Cooper, et al., 2020). Data are reviewed on a regular and systematic basis including visual graphs. In summary, the analysis of data drives changes to interventions. (Cooper, et al., 2020; BACB, 2020).

It is a common misconception that ABA itself is an autism intervention. ABA is not the teaching strategy in and of itself. ABA is the science behind how research is conducted, and educational and behavioral services are provided. There are many autism interventions based on the principles of ABA that have been demonstrated to increase learning and decrease challenging behavior in individuals with autism. These interventions are backed by decades of rigorous scientific research carried out by hundreds of individuals that demonstrate the efficacy of interventions based on the principles of ABA (Cooper et al., 2020). For a more detailed description of an ABA-based treatment program for autism, please click here. In treatment for autistic individuals and those with developmental disabilities, ABA has proven to be effective in supporting people across the lifespan in reaching goals to improve communication, social, and life skills that lead to greater independence and self-determination.

In autism treatment, ABA-based interventions and teaching techniques include, but are not limited to, breaking tasks into smaller components (task analysis, chaining), the use of antecedent interventions, modeling (both in real time and video), visual supports, and positive reinforcement. A particular focus in autism treatment is responding to challenging behavior that interferes with learning. The ultimate goal of a treatment program is to support the individual in acquiring new skills related to academics, language, communication, and social interactions to increase agency and independence to the fullest possible extent.

References:

Association of Professional Behavior Analysis (APBA). (2017). Identifying applied behavior analysis interventions. https://cdn.ymaws.com/www.apbahome.net/resource/collection/1FDDBDD2-5CAF-4B2A-AB3F-DAE5E72111BF/APBAwhitepaperABAinterventions.pdf

Baer, D. M., Wolf, M. M., & Risley, T. R. (1968). Some current dimensions of applied behavior Analysis. Journal of Applied Behavior Analysis, 1, 91-97.

Behavior Analyst Certification Board. (2022). Board certified behavior analyst handbook. Littleton, CO: Author. https://www.bacb.com/wpcontent/uploads/2022/01/BCBAHandbook_23102

Behavior Analyst Certification Board. (2022). Board certified assistant behavior analyst handbook. Littleton, CO: Author. https://www.bacb.com/wp-content/uploads/2022/01/BCaBAHandbook_231023-a.pdf

Behavior Analyst Certification Board. (2023). Registered behavior technician handbook. Littleton, CO: Author. https://www.bacb.com/wp-content/uploads/2022/01/RBTHandbook_231023-a.pdf

Behavior Analyst Certification Board. (2020). Ethics code for behavior analysts. https://bacb.com/wp-content/ethics-code-for-behavior-analysts/

Behavior Analyst Certification Board. (2018). RBT task list (2nd ed.). Littleton, CO: Author

Behavior Analyst Certification Board. (2017). BCBA task list (5th ed.). Littleton, CO: Author

Behavior Analyst Certification Board. (2020). BCaBA task list (5th ed.). Littleton, CO: Author

Behavior Analyst Certification Board. (2021). RBT ethics code (2.0). https://www.bacb.com/wp-content/rbt-ethics-code

Burgio, L. D., & Burgio, K. L. (1986). Behavioral gerontology: Application of behavioral methods to the problems of older adults. Journal of Applied Behavior Analysis, 19(4), 321-328.

Cooper, J. O., Heron, T. E., & Heward, W. L. (2020). Applied Behavior Analysis – 3rd ed. Prentice-Hall.

McKenna, K. & Huang, X. (2023). What can I expect from a quality ABA program? Science in Autism Treatment, 20(2).

Celiberti, D., Wirth, K., & McKenna, K. (2021). Humanity of ABA: ABA as a humane approach. In J. A. Sadavoy, & M. L. Zube. (Eds.), Scientific framework for compassion and social justice: Lessons from applied behavior analysis (1^st ed.). Routledge.

Fennell, B., & Dillenburger, K. (2014). The evidence debate for behavioural interventions for autism. International Research in Education, 2(2), 1-15. https://doi.org/10.5296/ire.v2i2.4989

Ghaemmaghami, M., Hanley, G. P., & Jessel, J. (2021). Functional communication training: From efficacy to effectiveness. Journal of Applied Behavior Analysis, 54(1), 122-143. https://doi.org/10.1002/jaba.762

Hanley, G. (2021, September 9). A perspective on today’s ABA from Dr. Hanley.
https://practicalfunctionalassessment.com/2021/09/09/a-perspective-on-todays-aba-by-dr-greg-hanley/

Harvey, M. T., Luiselli, J. K., & Wong, S. E. (2009). Application of applied behavior analysis to mental health issues. Psychological Services, 6(3), 212-222.

Parenti, K., & Rothman, H. (2023). What is the importance of engagement when working with individuals with intellectual and developmental disabilities and autism? Science in Autism Treatment, 20(01).

Peterson, K. M., Phipps, L., & Ibañez, V. F. (2022). Food-related disorders and applied behavior analysis. In J. L. Matson & P. Sturmey (Eds.) Handbook of Autism and Pervasive Developmental Disorder. Autism and Child Psychopathology Series. Springer, Cham. https://doi.org/10.1007/978-3-030-88538-0_44

Ruben, D. (2019). Behavioral forensics: Using applied behavior analysis in psychological court evaluations. Academic Press.

Silverman, K., Kaminski, B. J., Higgins, S. T., & Brady, J. V. (2011). Behavior analysis and treatment of drug addiction. In W. W. Fisher, C. C. Piazza, & H. S. Roane (Eds.), Handbook of applied behavior analysis (pp. 451-471). The Guilford Press.

Weatherly, J. N., & Flannery, K. A. (2008). Facing the challenge: The behavior analysis of gambling. The Behavior Analyst Today, 9(2), 130-142. https://doi.org/10.1037/h0100652

Citation for this article:

Gasiewski, K., & McKenna, K. (2023). Focus on the treatment team: Applied behavior analysis. Science in Autism Treatment, 20(12).

Other articles in this series

1. Description of the Treatment Team
2. Focus on the Treatment Team: Speech-Language Therapy
3. Focus on the Treatment Team: Occupational Therapy

About the Authors

Kristina Gasiewski, MOTR/L, MEd, BCBA received her Bachelor of Science in psychology and her Master of Occupational Therapy from University of the Sciences in Philadelphia. She went on to receive her Master of Education in autism and applied behavior analysis from Endicott College. Kristina works at Melmark PA, and recently has transitioned into her new role as the behavior analysist/QIDP in adult clinical services. Previously she worked as a school-based occupational therapist. Being dually credentialed, her research interests include collaboration between occupational therapists and behavior analysts and bridging the gap in order to best serve individuals with autism and developmental disabilities. Kristina is a member of the American Occupational Therapy Association (AOTA) as well as the Association for Behavior Analysis International (ABAI), and has had the opportunity to present at both organizations’ annual conferences. Additionally, Kristina is a Board member of the Association for Science in Autism Treatment (ASAT). 

Kate McKenna, MEd, MSEd, MS, BCBA, LBA, received a Masters in Child Study from the Eliot-Pearson Department of Child Study at Tufts University, a Masters in Special Education from Pace University, and a Masters in ABA from Hunter College.  In addition to New York state certifications in general and special education from Birth to Grade 2 and Grades 1-6, she holds a New York State Annotated Certification in Severe/Multiple Disabilities. Kate is currently completing a Masters degree in Children’s Literature at Eastern Michigan University.  She was an extern at the Association for Science in Autism Treatment before joining the Board of Directors in 2020.

By Ashleigh Evans, MS, BCBA

‘Tis the season for joy and excitement. Perhaps a bit of stress and chaos too. October through December can be exhausting for many families. With holidays back to back, it can be challenging to maintain a comfortable routine. Children with autism tend to thrive on structure and routine, making these months particularly challenging. Rest assured, there are strategies you can take to prepare your child and your family for these major upcoming changes.

Plan ahead

Sudden or unexpected changes are often the most difficult for children with autism to cope with. When children are primed in advance for the upcoming holidays, this can greatly improve their response when the holiday events come along.

Holiday preparation strategies might include any number of the following:

• Talk to your child often about the holidays and specifically what activities you all will be doing. For example, you might focus on Thanksgiving, discussing how you’ll be going to dinner at Grandma and Grandpa’s house that day.
• Read social stories and/or books about the holiday and associated events. Social stories are great for outlining and reviewing exactly what the plans and expectations are.
• Create a visual countdown or a calendar that shows when the holidays are to serve as a visual reminder of the upcoming events. Prompt your child to reference this visual each day as you discuss the upcoming holiday.
• Make backup plans in case things don’t go quite as planned.
• Prepare a holiday bag with any supports your child might need. Depending on what their individual needs are, this bag might include things such as noise-reducing headphones, fidgets, or weighted vests.
• Ensure your child has a way to safely escape if the setting becomes too overwhelming. For example, establish a dedicated location where they can go to calm down at each holiday event.

Maintain consistency where possible

With so much out of the ordinary during the holidays, it’s a good idea to try to avoid unnecessary major changes during these times. This isn’t always possible as life can be unpredictable. However, to whatever degree possible, maintain a consistent routine for your family.

Prioritize activities

With each holiday, there is an abundance of possible ways to celebrate, from large family gatherings and public outings to independent activities. The ways we celebrate holidays are often tied to sentimental family traditions. As such, it can be challenging to branch off from those activities that are special to us. It may, however, be helpful to prioritize the activities that are most important and most enjoyable to you and your family. If a particular holiday tradition historically causes more stress than enjoyment, consider alternative activities you can try that may be just as special to your family. Take your child’s preferences into consideration when planning events as well.

Be flexible

Sometimes our best-laid plans simply don’t work out. We might think our child can handle a new activity this year, but it still turns out to be overstimulating for them. Try to go into the holidays with a flexible mindset. If things don’t go quite as planned, have a backup plan prepared for alternative activities.

Recognize the progress, no matter how small

Focus on the victories, whether great or small. Holidays can be both magical and taxing on the whole family. Don’t forget to take the time to acknowledge the growth that your child has made. Happy holidays to all!

About the Author

Ashleigh Evans, MS, is a Board Certified Behavior Analyst. She has been practicing in the behavior analysis field for over 13 years and opened her own independent practice in early 2022. Her experience has been vast across different age groups, diagnoses, and needs. She is passionate about improving the field through education, reformative action, and better supervisory practices, leading her to create content and resources for families and ABA professionals which can be found on her website, www.evansbehavioralservices.com/.

Originally published November 11, 2022 by Different Roads to Learning.

This month’s ASAT feature comes to us from Lisa Tereshko, Ph.D., BCBA-D, Endicott College. To learn more about ASAT, please visit their website at www.asatonline.org. You can also sign up for ASAT’s free newsletter, Science in Autism Treatment, and like them on Facebook!

Everyday all individuals complete a variety of sequences of behaviors that were taught to them at some point in their lives. Some of these sequences include getting dressed, packing a lunch for school or work, and cooking dinner. Independently completing these sequences are essential for one to have independence throughout their day. One way of teaching sequences of behavior is using visual activity schedules. Visual activity schedules are an arrangement of pictures or words used to display a sequence of upcoming events. For example, when teaching getting dressed, a visual activity schedule might include a picture of under garments that signals the individual to put those on first, then a picture of a shirt signaling the next item to put on, and so on until the individual is completely dressed. This visual activity schedule could be posted on the side of the dresser of clothes or on the closet door.

Visual activity schedules encompass three evidence-based strategies: antecedent interventions, prompting, and visual supports (Hume et al., 2021). They are antecedent interventions in that they are presented prior to the initiation of the task as a cue to help the individual understand what is expected of them. The presentation of the visual activity schedule before the activity may also reduce the likelihood of challenging or interfering behaviors that could occur if the individual is frustrated because they do not understand the expectations or are disinclined to do the activity. Visual activity schedules also serve as a prompt, or support, that can increase the individual’s success completing the activity or task. Finally, visual activity schedules are a visual support as they are an additional visual stimulus that can support an individual’s increased independence and decrease their reliance on others for assistance.

The use of visual activity schedules can benefit all individuals to increase productivity and success across the day. People use various forms of visual activity schedules to complete a variety of activities throughout their day (e.g., to-do lists, daily planners, and following written directions). For individuals with autism/autistic individuals, visual activity schedules can be further beneficial by increasing independence. Individuals with autism/autistic individuals frequently display prompt dependency on another individual (Koyama & Wang, 2011). The use of visual activity schedules as a visual prompt can allow the individual to prompt themselves or rely on environmental cues rather than other people. The addition of visual activity schedules can additionally benefit individuals with autism/autistic individuals by reducing the auditory information they need to process. Previous research has shown that auditory information can be difficult for individuals with autism/autistic individuals to interpret (Knight et al., 2015); therefore, strategies relying on visual input may be more beneficial.

Visual activity schedules can take many forms (Koyama & Wang, 2011; Knight et al., 2015). The presentation of pictures can be displayed either in a linear (vertical or horizontal) pattern or within a small book (with one picture per page) where the individual engages with the schedule by moving the icon to a “done” column, checking it off a list, sliding a bar to indicate completion, or turning a page. It can also be modified to include actual objects to cue the activity for individuals who may have more difficulty identifying pictures (Hugh et al., 2018). For individuals who have word identification skills, visual activity schedules may also be presented in a narrative format where words replace pictures. Furthermore, technological advances have led to many options for the presentation of visual activity schedules as pictures or videos, and in the context of apps on tablets or other electronic devices.

Research Summary

There is a growing body of research that supports the use of visual activity schedules to increase a variety of skills and to assist with the reduction of interfering behaviors for individuals with autism/autistic individuals. According to the National Standards Project: Phase 2 (2015), the use of schedules with children with autism/autistic individuals is an established intervention that has been shown to increase their independence and their ability to plan for events that are upcoming. Furthermore, in a review by Hume et al. (2021) that evaluated evidence-based treatments for individuals with autism/autistic individuals, the authors provided additional support for visual activity schedules by identifying visual supports as an evidence-based practice.

Two systematic literature reviews have provided further support for the use of visual activity schedules as an evidence-based intervention. The review conducted by Koyama and Wang (2011) identified 23 peer reviewed studies that evaluated the use of visual activity schedules. They found that visual activity schedules had been effectively used to teach individuals with autism and intellectual disabilities to engage in a variety of activities, including on-task behavior. Knight et al. (2014) conducted another comprehensive review of the literature to expand the findings of past reviews and to determine if the use of visual activity schedules continued to be an evidence-based procedure. Their review identified 31 articles that targeted the use of visual activity schedules with individuals with autism/autistic individuals. The researchers found that visual activity schedules were effective for teaching a variety of skills across the lifespan of individuals with autism/autistic individuals. Furthermore, they found that the use of visual activity schedules was a low-effort intervention that provided individuals with consistent cues about upcoming events.

The use of visual activity schedules has been successful in teaching individuals with autism/autistic individuals across ages a variety of skills and activities such as completing the steps of toothbrushing (Moran et al., 2022), completing medical exams (Chebuhar et al., 2013), getting ready for bed (Hart Barnett et al., 2022),and leisure or play skills (Koyama & Wang, 2011). Furthermore, in the articles reviewed by Koyama and Wang (2011), there were 69 total participants including preschool students (24.6%), school-aged students (30.4%), and adults (23.2%) and more than half of those individuals had a diagnosis of autism (59.4%). Some recent literature supports the use of visual activity schedules with individuals with autism/autistic individuals to increase compliance during physical activity (Becerra et al., 2021), appropriate feeding behavior (Kirkpatrick et al., 2019), engagement in academic tasks while maintaining low rates of interfering behavior (Boyle et al, 2021), choice-making (Deel et al., 2021), completion of job-related tasks (Lora et al., 2020; Sances et al., 2019), completion of less preferred tasks without interfering behavior (Lory et al., 2020), successful transitions (Pierce et al., 2013), and social skills (Osos et al., 2021).

A variety of methods to implement visual activities is also supported in research. For some students, the use of video technology can be beneficial. Kirkpatrick et al. (2019) used video-enhanced activity schedules to reduce food stuffing (rapid eating), which resulted in a reduction of food stuffing and an increase in appropriate pacing of the meal for the participant. Brodhead et al. (2018) successfully increased the variety of games played on a tablet using an activity schedule on the tablet. Burckley et al. (2015) used a tablet to implement a video activity schedule in the community to increase the shopping skills of a young adult with autism. In only three lessons, the video activity schedule substantially helped to increase the young adults’ shopping skills.

Similar results were found when a visual activity schedule delivered via a smartphone was implemented in the community to teach an individual with autism to order items from a bakery (Cheung et al., 2016). Even a smart watch can be used to implement visual activity schedules, as shown by Jimenez-Gomez et al. (2021) when they increased the independence of play skills for three young children with autism/autistic children. The use of technology, such as tablets, smartphones, and smartwatches, may help to enhance the reach of visual activity schedules by increasing their portability and reducing the social stigma that may be associated with carrying a visual activity schedule into the community.

Though there is much research supporting the use of visual activity schedules. There are some cautions to note when examining their use. Knight et al. (2014) found that all but three studies used visual activity schedules in combination with other systematic instruction (e.g., graduated guidance, reinforcement, and prompting), which could have enhanced the effects. The maintenance and generalization of the use of visual activity schedules have limited research and represent an important direction for future research. With that said, the limited research that has been conducted appears promising. For example, MacDuff et al. (1993) successfully used visual activity schedules to teach on-task behavior that then generalized to novel pictures and activities in the schedule. Furthermore, Koyama and Wang (2011) noted that those studies that included maintenance information were able to successfully maintain the use of the visual activity schedule and those that did include generalization were successful with generalizing to novel activities or settings.

Recommendations

The application of visual activity schedules has been well documented in the research to be a successful intervention to increase a variety of skills across a variety of ages of individuals with autism/autistic individuals. This literature review is aligned with the National Standards Project: Phase 2 and other systematic literature reviews (e.g., Knight et al., 2014; Koyama and Wang, 2011) that support the recommendation to use visual activity schedules as an intervention for increasing skills and independence for individuals with autism/autistic individuals. Although research supports the success of visual activity schedules with individuals with autism/autistic individuals, the determination of appropriate intervention techniques for everyone should be decided by the team directly involved with that individual.

When using activity schedules with an individual with autism/autistic individual, it is important to consider the individual’s skills associated with symbolic representations, receptive language, and reading and comprehension when determining the mode of implementation (Hugh et al., 2018). Additionally, individual preference should be considered when determining the modality of the visual activity schedule (Knight et al., 2015). Giles et al. (2017) found similar acquisition rates when comparing static pictures to tablet-based modalities and preference for the different formats was idiosyncratic across participants. Additional clinical considerations include attention to assent and to the development of component skills. Specifically, learner assent should be assessed and regularly revisited; intervention should continue in the context of willingness and engagement (Morris et al., 2021). Component skills that can be built incidentally include choice-making, stamina for independent tasks, appropriate social engagement during activities, and self-monitoring. Many work-relevant skills can be shaped through the use of activity schedules.

Continued research should continue to explore the long-term effects of visual activity schedules and their ability to generalize effects across environments. The use of technology with visual activity schedules may help reduce the social stigma of some modalities of visual activity schedules and should continue to be explored to assist individuals in increasing their independence. While we await additional research, visual activity schedules remain an evidence-based intervention that can be valuable in increasing sequences of behavior for individuals with autism/autistic individuals.

Selected References

Systematic Reviews and Task Forces

Hume, K., Steinbrenner, J. R., Odom, S. L., Morin, K. L., Nowell, S. W., Tomaszewski, B., Szendrey, S., McIntyre, N. S., Yücesoy-Özkan, S., & Savage, M. N. (2021). Evidence-based practices for children, youth, and young adults with autism: Third generation review. Journal of Autism and Developmental Disorders 51, 4013-4031. https://doi.org/10.1007/s10803-020-04844-2

Knight, V., Sartini, E., & Spriggs, A. D. (2015). Evaluating visual activity schedules as evidence-based practice for individuals with autism spectrum disorders. Journal of Autism and Developmental Disorders, 45, 157-178. https://doi.org/10.1007/s10803-014-2201-z

Koyama, T., & Wang, H. T. (2011). Use of activity schedule to promote independent performance of individuals with autism and other intellectual disabilities: A review. Research in Developmental Disabilities, 32, 2235-2242. https://doi.org/10.1016/j.ridd.2011.05.003

National Autism Center. (2015). Findings and conclusions: National Standards Project, Phase 2. Author.

Selected Scientific Studies

Becerra, L. A., Higbee, T. S., Vieira, M. C., Pellegrino, A. J., Hobson, K. (2021). The effects of photographic activity schedules on moderate-to-vigorous physical activity in children with autism spectrum disorder. Journal of Applied Behavior Analysis, 54(2), 744-759. https://doi.org/10.1002/jaba.796

Boyle, M. A., Bacon, M. T., Sharp, D. S., Mills, N. D., & Janota, T. A. (2021). Incorporating an activity schedule during schedule thinning in treatment of problem behavior. Behavioral Interventions, 36, 1052-1064. https://doi.org/10.1002/bin.1813

Brodhead, M. T., Courtney, W. T., & Thaxton, J. R. (2018). Using activity schedules to promote varied application use in children with autism. Journal of Applied Behavior Analysis, 51(1), 80-86. https://doi.org/10.1002/jaba.435

Burckley, E., Tincani, M., & Fisher, A. G. (2015). An iPad-based picture and video activity schedule increases community shopping skills of a young adult with autism spectrum disorder and intellectual disability. Developmental Neurorehabilitation, 18(2), 131-136. https://doi.org/10.3109/17518423.2014.945045

Chebuhar, A., McCarthy, A. M., Bosch, J., & Baker, S. (2013). Using picture schedules in medical settings for patients with autism spectrum disorder. Journal of Pediatric Nursing, 28, 125-134. https://doi.org/10.1016/j.pedn.2012.05.004

Cheung, Y., Schulze, Leaf, J. B., & Rudrud, E. (2016). Teaching community skills to two young children with autism using a digital self-managed activity schedule. Exceptionality, 24(4), 241-250. https://dx.doi.org/10.1080/09362835.2016.1215654

Deel, N. M., Brodhead, M. T., Akers, J. S., White, A. N., & Miranda, D. R. G. (2021). Teaching choice-making within activity schedules to children with autism. Behavioral Interventions, 36, 731-744. https://doi.org/10.1002/bin.1816

Giles, A., & Markham, V. (2017). Comparing book- and tablet- based picture activity schedules: Acquisition and preference. Behavior Modification, 41(5), 647-664. https://doi.org/10.1177/0145445517700817

Hart Barnett, J. E., Zucker, S. H., & More, C. M. (2022). Visual schedule to promote compliance with bedtime routine in a child with autism spectrum disorder. Education and Training in Autism and Developmental Disabilities, 57(2), 196-203.

Jimenez-Gomez, C., Haggerty, K., & Topcuoglu, B. (2021). Wearable activity schedules to promote independence in young children. Journal of Applied Behavior Analysis, 54(1), 197-216. https://doi.org/10.1002/jaba.756

Lora, C. C., Kisamore, A. N., Reeve, K. F., & Townsend, D. B. (2020). Effects of a problem-solving strategy on the independent completion of vocational tasks by adolescents with autism spectrum disorder. Journal of Applied Behavior Analysis, 53(1), 175-187. https://doi.org/10.1002/jaba.558

Lory, C., Rispoli, M., Gregori, E., Kim, S. Y., & David, M. (2020). Reducing escape-maintained challenging behavior in children with autism spectrum disorder through visual activity schedule and instructional choice. Education and Treatment of Children, 43, 201-217. https://doi.org/10.1007/s43494-020-00019-x

Kirkpatrick, M., Lang, R., Lee, A., & Ledbetter-Cho, K. (2019). A video-enhanced activity schedule reduces food stuffing in child with pervasive developmental disability: A single subject design case study. Advances in Neurodevelopment Disorders, 3, 281-286. https://doi.org/10.1007/s41252-019-00100-6

Moran, K., Reeve, S. A., Reeve, K. F., DeBar, R. M., & Somers, K. (2022). Using a picture activity schedule treatment package to teach toothbrushing to children with autism spectrum disorder. Education and Treatment of Children, 45, 145-156. https://doi.org/10.1007/s4349-022-00074-6

Osos, J. A., Plavnick, J. B., & Avendaño, S. M. (2021). Assessing video enhanced activity schedules to teach social skills to children with autism spectrum disorder. Journal of Autism and Developmental Disorders, 51, 3235-3244. https://doi.org/10.1007/s10803-020-04784-x

Pierce, J. M., Spriggs, A. D., Gast, D. L., & Luscre, D. (2013). Effects of visual activity schedules on independent classroom transitions for students with autism. International Journal of Disability, Development and Education, 60(3), 253-269. http://dx.doi.org/10.1080/1034912X.2013.812191

Sances, J., Day-Watkins, J., & Connell, J. E. (2019). Teaching an adult with autism spectrum disorder to use an activity schedule during a vocational beekeeping task. Behavior Analysis in Practice, 12, 435-439. https://doi.org/10.1007/s40617-018-00306-5

Other Works Cited Above

Hugh, M. L., Conner, C., & Stewart, J. (2018). Intensive intervention practice guide: Using visual activity schedules to intensify academic interventions for young children with autism spectrum disorder. National Center for Leadership in Intensive Intervention. https://files.eric.ed.gov/fulltext/ED591075.pdf

Morris, C., Detrick, J. J., & Peterson, S. M. (2021). Participant assent in behavior analytic research: Considerations for participants with autism and developmental disabilities. Journal of Applied Behavior Analysis, 54(4), 1300-1316. https://doi.org/10.1002/jaba.859

Citation for this article

Tereshko, L. (2023). A treatment summary of visual activity schedules. Science in Autism Treatment, 20(6).

About the Author

Dr. Lisa Tereshko, Ph.D., BCBA-D, LABA is the Director of Quality Assurance and Research for the Institute of Applied Behavioral Science at Endicott College. Lisa has over 20 years of experience working with individuals with autism and other behavioral disorders in schools, homes, and residential settings. Her research interests include: the effectiveness and efficiency of functional analyses, ethical and compassionate feeding interventions, increasing cultural competency in higher education, and identifying best pedagogical practices within higher education in which she has published peer-reviewed articles, books, and chapters. She has presented locally, nationally, and internationally on many topics, serves on committees at BABAT and at ASAT, and is on the editorial board of Behavior Analysis in Practice.  

Reposted with permission from Action Behavior Centers

Applied Behavior Analysis (ABA) therapy is an evidence-based approach to treating children with Autism Spectrum Disorder (ASD). When ABA therapy is implemented in a center-based environment, it takes place in a clinical or therapy center to provide structure. This allows for the environment to be controlled. It involves a consistent approach to therapy, provided by a team of trained professionals like Board Certified Behavior Analysts (BCBA) and Registered Behavior Technicians (RBT).

The goal of center-based ABA therapy is to teach children on the autism spectrum new skills and behaviors while reducing unwanted behaviors. This is accomplished through a process of breaking down complex skills into smaller, more manageable steps and using positive reinforcement to motivate and encourage progress. At Action Behavior Centers, center-based ABA therapy sessions run from Monday to Friday at 8AM to 5PM. During each therapy session, the child may engage in a variety of activities designed by our therapist to help them develop new skills and behaviors. This form of therapy includes a variety of activities, such as play-based activities, structured teaching activities, and social skills training. For example, they may work on communication skills, social skills, and daily living skills. While working on a one-to-one therapist to child ratio, our therapist will evaluate each autistic child to implement a specific treatment plan. These plans will be designed to address the individual’s unique needs and goals. 

Center-based ABA therapy offers several advantages over the at-home alternative. Therapy centers offer an environment that is designed to be structured and predictable to allow ABA therapists the ability to conduct in a consistent and supportive manner. However, the benefits of center-based ABA therapy go beyond a controlled environment. Benefits of center-based Applied Behavior Analysis (ABA) therapy for children with autism include:

1. Peer Play, Social Imitation, and Social Interaction: One of the most significant benefits to in-center ABA therapy is the opportunity for children to connect with others their age. At Action Behavior Centers, our compassionate therapists supervise and guide child-to-child engagement. This gives ABA therapists the opportunity to teach children social skills such as how to greet others, initiate conversations, and join in on activities. This then translates into the development of other important skills like sharing and turn-taking. These skills can help children feel more comfortable and confident when interacting with peers and most importantly, it allows for peers to build friendships.
2. Increased Supervision: Being in a center-based ABA therapy program allows for your child’s therapist to connect to a larger body of professionals, ensuring your child is getting the best possible care and attention. Not only will your child be surrounded by a team of experts, but they’ll have access to more resources as well. Having a consistent team of clinical experts nearby creates a safe space for your child to explore and interact with their environment. At Action Behavior Centers, we employ trained professionals who have experience in working with children with autism. These professionals can provide individualized treatment plans and tailor therapy to the specific needs of the child. We make sure that our Board Certified Behavior Analysts (BCBAs), Registered Behavior Technicians (RBTs), and other therapists have had specialized training and experience in working with children with autism so that they can provide the most up-to-date form of ABA therapy possible. 
3. School Readiness: Children who attend ABA therapy in-center will be practicing school-readiness skills such as participating in group activities, imitation, matching, and categorizing. Children will begin to familiarize themselves with the drop-off and pick-up process, alleviating some of the transitional stress associated with entering the school environment. ABA therapists help autistic children develop communication skills such as expressing themselves effectively, asking for help, and following directions as these skills are essential for effective communication with teachers and classmates.
4. State of the Art Facilities: Each of our ABA therapy centers is created with your child’s specific needs in mind. From the big-picture ideas to the minute details, our New Center’s Team focuses on creating the perfect place for children to learn & grow – while making our therapists feel relaxed, happy, and engaged. The village build-outs are perfect for pretend play – creating a unique, imaginative experience for our children to engage with. Our centers have a variety of therapy spaces to accommodate different activities and interventions, such as individual therapy rooms, group therapy spaces, and play areas. With safety in mind, our autism clinics  are accessible for all clients, including those with physical disabilities or mobility impairments.
5. Structured Learning Environment: As previously stated, center-based settings provide a structured and controlled environment for ABA therapy to be implemented. This allows therapists to create a consistent and predictable routine for the child, which can aid in the child’s learning and behavioral management. Center-based ABA therapy provides a structured and consistent environment that is designed to support the learning and development of children with autism. This can be especially important for children who struggle with routine and structure in other areas of their lives.
6. Specialized Equipment: Centers often have specialized equipment and resources that can be used to aid in the therapy process. For example, therapy rooms may be equipped with toys and other materials that are specifically designed to help with skill development. For example, our ABC centers have access to specialized resources and materials, such as sensory equipment, communication devices, and other technology that is used to support learning and development. Our centers even have access to a wide range of resources that include educational resources. This can help to support the learning and development of children with autism.

Overall, center-based ABA therapy can provide the structure needed for a child with autism to learn and grow. It is important to note that while center-based ABA therapy can be beneficial for many children with autism, it may not be the best fit for every child. Center-based ABA therapy can provide valuable resources and support for parents and other caregivers that In-home ABA therapy can lack in. Each child has unique needs, strengths, and challenges, and families should work with their healthcare providers to determine the best approach for their child’s individual needs. 

About Action Behavior Centers

Action Behavior Centers (ABC) is an organization committed to the treatment of children using empirically validated methods and strategies to assist each child in reaching his or her greatest potential and improving their quality of life.

Learn more at their website: https://www.actionbehavior.com/

This month’s ASAT feature comes to us from Kate McKenna, MEd, MSEd, MS, BCBA, and Kristina Gasiewski, MEd, MOTR/L, BCBA, Association for Science in Autism Treatment. To learn more about ASAT, please visit their website at www.asatonline.org. You can also sign up for ASAT’s free newsletter, Science in Autism Treatment, and like them on Facebook!

This is part of the Description of the Treatment Team series.

History

Occupational therapy (OT) was established in 1917 by six founders of the National Society for the Promotion of Occupational Therapy (NSPOT). This Society was later renamed in 1923 and is currently known as the American Occupational Therapy Association (AOTA) (Paterson, 2011). The founders were from a variety of professional backgrounds and disciplines (i.e., psychiatrists, architects, welfare workers, teachers, nurses, and medical doctors) who came together with one strong belief that occupations hold a therapeutic value. The values and beliefs that most OTs hold today were created and shaped by the 19^th and early 20^th-century historical events such as industrialization, women’s rights, World War I, healthcare legislation, and technology (Christiansen & Haertl, 2019).

As a discipline, OT rose to prominence following WW1 as the medical professionals working with shell-shocked and wounded veterans. In their efforts to rehabilitate those suffering the effects of combat, the original practitioners of OT based their profession on the idea that real work would aid in creating a healthy body and mind (Christiansen & Haertl, 2019). As a result of their success, OT came to be recognized as a medical discipline in its own right.

By the 1960s, there were two distinct practice areas including treating those with physical disabilities and those with psychological dysfunction. Some key events that influenced the OT profession stemmed from the civil rights movement and its influence on health care and social justice, and large mental institutions closing (which affected the number of OT professionals working in longer-term mental health settings). The American Occupational Therapy Foundation (AOTF) was founded in 1965 to promote scientific development in the field of OT. At this time, there was also increased emphasis on sensorimotor therapies and neurodevelopmental theories (Christiansen & Haertl, 2019).

In the 1970s, OT was again influenced by the medical rehabilitation and treatment of war veterans. This created a shift from a holistic and occupation-based approach to a more medical, bottom-up approach with an emphasis on the source of the problem. This was a shift from the root of OT as of a top-down approach and utilizing occupations and crafts in a therapeutic manner. OT practitioners began focusing more on theory and research. Mechanical approaches were being applied to interventions such as the neuromotor and musculoskeletal systems and their relation to occupational function (Christiansen & Haertl, 2019).

With advances in science, technology, education, and health care during the 1980s and 1990s, the OT profession continued to evolve. There was a greater emphasis on research, efficacy, and defining the scope of practice. In 1986, AOTA created the American Occupational Therapy Certification Board (AOTCB), which, in 1996, was later named the National Board for Certification in Occupational Therapy (NBCOT) (Christiansen & Haertl, 2019). Regulations requiring licensure for OT became effective on July 1, 1998. Additionally, in 1999, the first edition of the American Journal of Occupational Therapy (AJOT) was published. Also, in 1997, the Individuals with Disabilities Education Act (IDEA) was passed, which ensures specialized services, including OT, are provided for children with disabilities in schools in order to improve education. This led to an increase in the number of OT practitioners working in school systems increased (Christiansen & Haertl, 2019).

Legislation and policies continue to change and heavily influence the OT profession such as increasing the quality of practice through measurable outcomes, creating goals that contain cost, and providing evidence-based research that demonstrates the effectiveness and efficacy of OT practice (Christiansen & Haertl, 2019).

Education

Occupational Therapy professionals acquire their degrees from an ACOTE (Accreditation Council for Occupational Therapy Education) accredited occupational therapy program. There are two degrees: occupational therapy assistant (OTA) and occupational therapist (OT).

An OTA may practice with an associates degree under the supervision of a licensed OT. An OT must obtain a Masters level degree to practice. However, those who acquired and have been practicing prior to 1990 may continue to practice with a bachelor’s degree. There are both post-professional master’s programs for those that hold an approved bachelor’s degree in a related field, and entry-level master’s degree programs. Additionally, there are entry-level occupational therapy doctorate (OTD) programs. At this time, the profession runs under a dual-entry point. There was a proposal to mandate a doctorate-level requirement; however, in 2019, after much debate, AOTA, who presides over ACOTE, upheld the dual point of entry policy.

Some typical courses of study may include anatomy and physiology, kinesiology, movement analysis, neuroscience, adult rehabilitation, assistive technology, occupations across the lifespan, and assessing occupational performance. Additionally, OTA and OT students must complete fieldwork consisting of two levels. Level I fieldwork typically consists of observations and shadowing OTs in multiple settings; however, there has been a bigger push to allow more hands-on opportunities during these practicums. Level II fieldwork requires a minimum of 16 weeks for OTA students and at least 24 weeks for OT students. This must occur across two different settings and requires the OT student to work directly with clients under the supervision of a licensed OT.

Standards of Practice & Guiding Documents

Once graduated, OTs and OTAs must pass the National Board for Certification in Occupational Therapy (NBCOT) exam in order to practice. Currently, all 50 states, Guam, Puerto Rico, and the District of Columbia require the NBCOT initial certification. For OTs, this test is comprised of 3 clinical simulation test items and 170 multiple-choice single-response questions. The OTA exam consists of 200 questions of both multiple-choice, single-response questions and six option multi-select questions. Passing the exam, therapists become certified and assume the following credential: OTR – Occupational Therapist Registered, or COTA – Certified Occupational Therapy Assistant. The NBCOT requires 36 units of continuing education during a three-year renewal cycle to be in good standing with the OTR NBCOT Practice Standards, the COTA NBCOT Practice Standards, and the NBCOT Code of Conduct. A list of renewal activities can be found here: NBCOT® Certification Renewal Activities.

OT professionals must be licensed per the state they work in, and state licensing requirements vary per state. It should be noted that while each state requires the initial passing of the NBCOT exam and to be registered with NBCOT, it may not be a requirement to continue this certification. Therefore, you may see two different credentials: Occupational Therapist Registered/Licensed (OTR/L) or Occupational Therapist/Licensed (OT/L).

Additionally, COTAs practice under the ongoing supervision of a licensed OT. The amount and level of supervision is guided per state regulations as well as the type of setting and insurance protocols.

As licensed professionals, OTs practice under a set of guiding documents created to guide OTs in effective and ethical provision of services, to protect consumers, and to establish a common understanding of the basic principles of the profession. Guiding OT documents include the Occupational Therapy Practice Framework (OTPF)-4 (2020), the Occupational Therapy Scope of Practice (2021), the Standards of Practice for Occupational Therapy (2021), and the Occupational Therapy Code of Ethics (2020).

Professional Organizations

There are a number of professional organizations open to membership by OTs, including the American Occupational Therapy Association (AOTA), the American Occupational Therapy Foundations (AOTF), the Canadian Association of Occupational Therapists, and the World Federation of Occupational Therapists (WFOT). Benefits of membership in these organizations include on-site access to peer-reviewed journals, attendance at conferences and webinars for professional development, and the organization’s legislative advocacy for both practitioners and clients.

Scope of Practice

A glance through the titles of some of the peer-reviewed journals published in the field of OT gives us a sense of the areas in which OTs practice. The specificity makes clear that OT is a broad field that impacts the lives of people with a range of support needs, in a variety of settings.

Published by AOTA:

• American Journal of Occupational Therapy (AJOT)
• AOTA’s OT Practice
• SIS (Special Interest Sections) Quarterly Practice Connections

AOTA members also have access to the following external journals:

• Occupational Therapy Journal of Research (OTJR): Occupation, Participation, and Health
• Australian Occupational Therapy Journal
• Canadian Journal of Occupational Therapy
• British Journal of Occupational Therapy
• Open Journal of Occupational Therapy (OJOT)

Some additional occupational therapy-based journals include:

• Physical and Occupational Therapy in Pediatrics
• American Journal of Physical Medicine & Rehabilitation
• Occupational Therapy in Health Care
• Journal of Occupational Therapy, Schools, and Early Intervention
• Journal of Hand Therapy
• Physical and Occupational Therapy in Geriatrics

Areas of focus in OT can be categorized into two domains: Activities of Daily Living (ADLs), which include supporting competency and independence in areas such as feeding, dressing, and grooming, and Instrumental Activities of Daily Living (IADLs). IADLs are activities that bring people in contact with their environments such as shopping, managing money, traveling, work, and leisure activities. Other activities that come under the heading of IADLs revolve around independent living. Meal preparation, household chores, health management, education, and personal safety are examples (OT Scope of Practice, 2021; OTPF-4, 2020). Supporting progress in these activities may involve adapting or modifying the environment and conducting an activity analysis to pinpoint the specific skills that require work.

OTs are employed in a variety of settings such as schools, hospitals, both long-term care facilities for those with memory loss or extensive care needs and outpatient clinics, and in the home or other community settings. OT practitioners work on refining fine motor manipulation (i.e., finger dexterity, in-hand manipulation, bilateral coordination, etc.) in order to improve the overall function of skill (i.e., self-care skill, handwriting, keyboarding, etc.). OTs also have the expertise to assess core strength and develop an intervention plan for postural control that may include providing adaptive seating equipment. OT practitioners may work with an individual to improve processing skills such as organizational skills and work on improving visual perceptual and motor planning skills (Schell & Gillen, 2019).

“Occupational Therapy has a long history that is steeped in cultural and historical events. Professionals who practice OT engage in rigorous coursework and clinical practice prior to passing a certification exam and have established many professional organizations and peer-reviewed journals to form a solid foundation of scientific evidence regarding their treatments. At the heart of OT is the goal of promoting participation in meaningful occupations, which are defined by OT practitioners as any activity in which an individual engages throughout their day. The field of OT focuses on teaching individuals, across the lifespan, the skills needed to promote independence and participation in daily life activities. (Schell & Gillen, 2019).

References

American Occupational Therapy Association (2021). Occupational Therapy Scope [KG1] of Practice. The American Journal of Occupational Therapy: Official Publication of the American Occupational Therapy Association, 75(Supplement_3), 7513410020. https://doi.org/10.5014/ajot.2021.75S3005

American Occupational Therapy Association. (2020). AOTA 2020 occupational therapy code of ethics. American Journal of Occupational Therapy, 74(Suppl. 3), 7413410005. https://doi.org/10.5014/ajot.2020.74S3006

American Occupational Therapy Association. (2021). Standards of practice for occupational therapy. American Journal of Occupational Therapy, 75(Suppl. 3), 7513410030. https://doi.org/10.5014/ajot.2021.75S3004

American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2), 7412410010. https://doi.org/10.5014/ajot.2020.74S2001

Christiansen, C. H., & Haertl, K. L. (2019). A contextual history of occupational therapy. In Schell, B. A. & Gillen, G. (Eds.), Willard & Spackman’s Occupational Therapy (13^th ed.). Williams & Wilkins.

Paterson, C. F. (2011). A short history of occupational therapy in psychiatry. In Cree, J. & Lougher, L. (Eds.), Occupational Therapy and Mental Health (4^th ed.). Elsevier Health Sciences UK.

Schell, B. A., & Gillen, G. (2019). Willard & Spackman’s Occupational Therapy (13^th ed.). Williams & Wilkins.

Citation for this article:

McKenna, K., & Gasiewski, K. (2022). Focus on the treatment team: Occupational therapy. Science in Autism Treatment, 19(12).

Other articles in this series

1. Description of the Treatment Team
2. Focus on the Treatment Team: Speech-Language Therapy

About the Authors

Kate McKenna, MEd, MSEd, MS, BCBA, LBA, received a Masters in Child Study from the Eliot-Pearson Department of Child Study at Tufts University, a Masters in Special Education from Pace University, and a Masters in ABA from Hunter College.  In addition to New York state certifications in general and special education from Birth to Grade 2 and Grades 1-6, she holds a New York State Annotated Certification in Severe/Multiple Disabilities. Kate is currently completing a Masters degree in Children’s Literature at Eastern Michigan University.  She was an extern at the Association for Science in Autism Treatment before joining the Board of Directors in 2020.

Kristina Gasiewski, MOTR/L, MEd, BCBA received her Bachelor of Science in psychology and her Master of Occupational Therapy from University of the Sciences in Philadelphia. She went on to receive her Master of Education in autism and applied behavior analysis from Endicott College. Kristina works at Melmark PA, and recently has transitioned into her new role as the behavior analysist/QIDP in adult clinical services. Previously she worked as a school-based occupational therapist. Being dually credentialed, her research interests include collaboration between occupational therapists and behavior analysts and bridging the gap in order to best serve individuals with autism and developmental disabilities. Kristina is a member of the American Occupational Therapy Association (AOTA) as well as the Association for Behavior Analysis International (ABAI), and has had the opportunity to present at both organizations’ annual conferences. Additionally, Kristina is a Board member of the Association for Science in Autism Treatment (ASAT).