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Sample Healthcare Paper
Healthcare Policy/ ABA Therapy

Abstract

A policy is simply a set of accepted principles that guide given practice. Every aspect of healthcare exists at the backdrop of some policy framework. Policies are among the most important requirements of quality and safe healthcare systems. The World Health Organization (2010) describes an ideal healthcare system as one that has a steady financial system, properly established framework that guides decisions, highly competent and specialized staff and properly maintained facilities. Policies evolve from research and practice. The main interest of this paper is on the applied behavioural analysis (ABA) therapy policy and practice. It proposes an updated ABA therapy practice that is evidence-based, recognizes and documents the limitations of ABA itself, safer and opens room for integration of other methods of treatment to cover the wide spectrum of symptoms of autism in children.

 

Introduction

Applied behavioural analysis (ABA) is one of the most proven methods used to treat autism spectrum disorders (ASD). ASD is a form of disability that shows early signs in childhood. It is described as a ‘spectrum’ because the symptoms vary from one patient to another and over time (Donaldson & Stahmer, 2014). As a result, it is difficult to treat ASD. The Centres for Disease Control and Prevention (2015) has identified common symptoms of ASD in children. These include strict repetitive patterns of behaviour, impaired social skills, especially lack of ability to form and keep social relationships, retarded growth in cognitive functions, and poor or uncoordinated use of language.

The ABA method is also known as behavioural treatment or behavioural intervention. In a typical ABA session, the therapist employs scientifically proven cognitive behavioural techniques to stimulate and motivate physical activities and response to the environment. At the same time, the therapist strives to eliminate the ASD patients’ physical failures. The common techniques used in ABA include reward and praise, among others. The therapist first encourages the ASD patient to initiate certain activities. To form a habit, the therapist motivates the patient to repeat the activities. This routine is achieved by consistently rewarding the patient for every positive response to stimulation.

The key concern of this paper is on the benefits and limitations of the ABA method in the treatment of ASD among children. The basis of this paper is the view that, there seems to be a great research attention on the benefits of ABA compared to its weaknesses. The next section discusses some of the research findings on the benefits of ABA as a treatment option for ASD. It also underlines some of the weaknesses of ABA identified in the research. These weaknesses form the basis of the recommendations made to inform current policy and practice on ABA as a treatment intervention for ASD.

Discussion

An overwhelming chunk of research evidence has shown that ABA yields significant improvements in enhancing essential functional skills among autistic children. In a review of nine studies conducted between the years 2000 and 2011, Lopez et al. (2014) report that early intensive behavioural intervention (EIBI) leads to improvement in IQ and adaptive behaviours, linguistic skills, intellectual abilities, development of skills, interests and relationships among children with ASD. The studies reviewed in Lopez et al. (2014) do not identify any limitations or failures of ABA as a method. They neither discuss any inherent challenges faced by therapists in applying this method.

According to Kahoe (2015), ABA is a self-refining method that optimizes positive outcomes as it minimizes adverse effects. Again, like the studies in Lopez et al. (2014), this argument paints ABA therapy as a perfect procedure. Another study by Ivy and Schreck (2016) has found that ABA can engender positive outcomes throughout the lifespan of an ASD patient if it is administered at the right time and in the right manner. However, these authors do not specify what they mean by the right time and the right manner. Similarly, Eikeseth, Smith, Jahr and Eldevik (2014) argue that children at the most impressionable age of 4-7 years can benefit greatly from ABA intervention. From these studies, it is evident that ABA has a positive impact on the reduction of the symptoms of ASD in children.

Limitations of ABA

However, there are weaknesses inherent in the ABA method of therapy which the reviewed studies failed to mention. First, the method requires at least 40 hours of patient-therapist interaction per week (Devita-Raeburn, 2016). Such duration is quite unfeasible for two main reasons. In the first place, managing to enlist the concentration of a child with ASD could be a herculean task, even for the trained therapist. Moreover, for working parents, this duration may be too much to spare every week. The fact that ABA as an ASD intervention goes on throughout the lifetime of the child compounds this challenge. Therefore, the cumulative impact on the schedule for the parent could be damaging to other equally important engagements such as career commitments and growth.

Professional therapists are properly trained to withstand the frustrations when a child with ASD fails to make meaningful progress after long hours of ABA therapy. On the other hand, parents who witness dismal outcomes may not be able to withstand such failure. Some of them may even give up the entire treatment altogether due to burn-out or a sense of disappointment. Others may simply choose not to accompany the child during ABA sessions. A preliminary online search of the existing literature found no specific studies or publications on the psychological and social impact that ASD in children has on parents. Benyon (2014), writing in an online newspaper, identifies the financial challenges parents go through in seeking the right behavioural interventions for their autistic children.    

Second, the reward system used in ABA may at times be counterproductive. In the first place, it is important to realize that children with ASD may be very picky about objects that excite them. Therefore, choosing the most motivating reward may be difficult for both the parents and the therapist. The first few sessions may register very discouraging outcomes, especially for the parent. Even when one has found the most stimulating reward, the child may develop an interest in a different kind of reward after a given duration, meaning the therapist and the parent will have to go on another search for the right motivator. On the other hand, a child may be stimulated by the reward to respond to the requirements of the ABA therapist without actually internalising the desired social skill. How can parents and therapists truly ascertain that the so-called improved signs are actual skills gained and not merely responses to an external stimulus from the therapist? In such a scenario, it is possible for ABA therapists to fail to distinguish true outcomes from false ones. One of the dangers of this challenge is that it opens room for unethical practices among ABA therapists. For instance, a therapist may assure an unsuspecting parent that the child is making progress based on fake results.

Parker (2015) opines that ABA can be used to teach conformity instead of promoting healthy social criticism. Over time, the routine to which the ABA therapist subjects an autistic child becomes a dormant system that promotes compliance instead of psychological independence and creativity. In a related study, Morgenstern (2015) has found that schools that specialize in ABA, teachers and therapists tend to focus only on teaching children to pass examinations. These schools are keen on proving that their systems, methods and programmes work so as to get more parental and sponsor support. The focus of ABA therapy in such contexts is not on the holistic functional skills of the child. Such narrow focus ignores the cognitive independence and creativity of ASD patients.

Third, there is the challenge of cost. ABA treatment for ASD can be financially draining for families. Enrolling a child with ASD in a specialized school that offers ABA treatment can cost a family USD16,000 to USD25,000 per year per child. On the other hand, home-based therapy costs on average USD40,000 per year per child (Benyon, 2014). These figures suggest that some families may not afford to either enrol their children in ABA schools or hire an ABA therapist to give home care. All the weaknesses mentioned above can find amicable redress in strong policy and practice framework of ABA.

Policy recommendations

Before beginning ABA treatment, hospitals should first train parents on the magnitude of work to which they are about to engage themselves. The training will help parents to set aside time for the required weekly sessions. It will also enhance their motivation thus reducing the onset of burn-out and frustration due to dismal outcomes. This recommendation is in line with the view by Heitzman-Powell, Buzhardt, Rusinko and Miller (2013) that training of parents on ABA can save them the trips they have to make to the therapist. The authors suggest that online training of parents can promote parental involvement and motivation in the implementation of home-based ABA strategies. They advocate that parents should be facilitated to lead in the administration of ABA because they are the primary individuals with whom children are familiar. On their part, parents should also strive to understand and adjust to the demands of having a child with ASD.

Another important recommendation is that ABA sessions should be reduced from 40 to at least 20 hours a week. Long and intensive durations can be strenuous to the child, the therapist and the parent. Such strains negate the objectives of ABA therapy in ASD treatment. However, a reduced duration will allow the child to acquiesce to the treatment process easily. It will also reduce the strain that the ABA process places on parents and the therapists. This recommendation calls for the need to review programmes and methods in schools that specialize in ABA interventions for ASD. Such schools should endeavour to promote adaptive behaviour to near-normal social and physical environments. They should endeavour to stimulate the creative abilities of children instead of simply tailoring their programmes to ensure children pass examinations.

Lastly, ABA may not be effective for all children with ASD because the disorder shows different symptoms. Therefore, ABA is not the best intervention option for every child with ABA. However, it should be limited to the treatment of specific symptoms, such as communication impairment. Hospitals need to review the manner in which therapists apply ABA. It should be marked with variations of activities to create a near-normal environment for the child. Due to the intensity of the process, some ABA therapists may over-emphasize on one or some of the stimulus to the detriment of others.

Hospitals and therapists need to find ways to integrate ABA with other forms of therapies. Such integration would enable them to develop a comprehensive framework that can capture and provide a more reliable intervention to a wider range of ASD symptoms and patients. The CDC (2017) has proposed other forms of therapies that could work best with the ABA therapy. These include the Listening Programme, the Fast ForWord Programme, Speech therapy, the Picture Exchange Communication System (PECS) and the Sensory Integration.

According to Mosier (2011), it is necessary to use varied approaches in the application of ABA. In a study of the relative efficacy of discrete trial training (DTT) and natural environment training (NET), the author found that each of these methods had a significantly high impact on language learning. However, together, the results of the application of these methods far exceeded those of application of either DTT or NET. This conclusion hints on the importance of integrating other types of therapies into the ABA method in the treatment of ASD.

There is a need for greater oversight of the activities of ABA therapists. The concern should be the effect of the demands of their work on their stress and effectiveness levels. ABA therapists who administer home-based care for autistic children may not see the need to show accountability, especially where the parent is absent or is not knowledgeable on ABA and ASD. Therefore, supporting hospitals and healthcare administrators need to define the oversight policy on such healthcare professionals. The ABA method is a powerful tool for teaching behaviour. As such, it can also be abused to manipulate patients towards undesirable outcomes.

Summary

ABA is a revolutionary intervention in the treatment of ASD. In most cases, a properly planned and implemented ABA can enhance cognitive functions and behaviour in an ASD patient. However, it does not always yield the intended results. Indeed, ABA can be applied to teach harmful behaviour. It is equally time-consuming and costly. Moreover, since progress in ABA is never always linear, the process requires constant monitoring. These challenges can take a toll on both the ABA therapist and the parent. As a result, there are many incidences of misapplied ABA in the treatment of ASD. This paper has proposed some policy recommendations to enhance the application of ABA as an intervention of ASD. The paper argued that most researchers of ABA are concerned with its benefits and that few studies have focused on its weaknesses. This argument was informed by a preliminary review of existing literature. Perhaps a more detailed review of existing works could expand or appraise this paper’s argument. A comprehensive empirical review of ABA in practice could also shed more light on the discussed benefits and weaknesses.   

 

 

References

Benyon, L. (2014, July 22). How a controversial therapy has changed my autistic daughter's life. Express UK. Retrieved July 10, 2017 from http://www.express.co.uk/life-style/life/490359/applied-behaviour-analysis-helped-daughters-autism

Centres for Disease Control and Prevention (2015). Autism Spectrum Disorder (ASD): Signs and symptoms. Retrieved July 10, 2017 from https://www.cdc.gov/ncbddd/autism/signs.html

Centres for Disease Control and Prevention (2017). Autism Spectrum Disorder (ASD): treatment. Retrieved July 10, 2017 from https://www.cdc.gov/ncbddd/autism/treatment.html

Devita-Raeburn, E. (2016, August 11). Is the Most Common Therapy for Autism Cruel? Retrieved July 10, 2017 The Atlantic. https://www.theatlantic.com/health/archive/2016/08/aba-autism-controversy/495272/

Donaldson, A., & Stahmer, A. (2014). Tam Collaboration: The use of Behavior Principles for Serving Students with ASD. Language, Speech and Hearing Services in Schools, 45, 261-276.

Eikeseth, S., Smith, T., Jahr, E., & Eldevik, S. (2014). Outcome for Children With Autism Who Began Intensive Behavioral Treatment Between Ages 4 And 7: A Comparison Controlled Study. Behavior Modification, 264-278.

Heitzman-Powell, L. S., Buzhardt, J., Rusinko, L. C., Miller, T. M. (2013). Formative Evaluation of an ABA Outreach Training Program for Parents of Children With Autism in Remote Areas. Sage Journals, 29(1), 23-38.

Ivy, J. W., & Schreck, K. A. (2016). The Efficacy of ABA for Individuals with Autism Across the Lifespan. Curr Dev Disord Rep., 3, 57-66.

Kehoe, M. (2015). The Effectiveness of Applied Behavior Analysis. Education Masters. Paper 307. St. John Fisher College.

Lopez, B., Benvenuti, M., Diaz, A., Ferrara, M., Gerdener, M., Kargas, N., Long, N., Munoz, M., Niccolai, F., Wakeford, S. A. (2014). Early Intensive Behavioural Interventions. Research Update, no. 13. Autism Research Network, Department of Psychology, University of Portsmouth.

Morgenstern, B. D. (2015). Teaching Functional Skills to Individuals with Autism and other Developmental Disabilities. Institute of Professional Practice.

Mosier, A. K. Ms. (2011). Applied Behavior Analysis Techniques: Discrete Trial Training & Natural Environment Training. Research Papers. Paper 226. Southern Illinois University Carbondal.

Parker, S. (2015, March 20). Autism: does ABA therapy open society's doors to children, or impose conformity? The Guardian. Retrieved July 10, 2017 from https://www.theguardian.com/society/2015/mar/20/autism-does-aba-therapy-open-societys-doors-to-children-or-impose-conformity

Peters-Scheffer, N., Didden, R., Korzilius, H., & Sturmey, P. (2011). A meta-analytic study on the effectiveness of comprehensive ABA-based early intervention programs for children with Autism Spectrum Disorders.

World Health Organization (2010). Key components of a well-functioning health system. Retrieved July 10, 2017 from http://www.who.int/healthsystems/publications/hss_key/en/