Behavior Therapy Beyond Childhood

Thomas Frazier, Ph.D.
The Section of Behavioral Medicine

Leslie Sinclair, M.A., CCC/SLP, BCBA
Program Director, Center for Autism

Cleveland Clinic
Cleveland, Ohio, United States
Email: FRAZIET2@ccf.org

Date First Published: January 24, 2008

Myth: Intensive Behavioral Intervention Is Only for Young Children

Controversy and myths in autism and autism treatment continue to proliferate throughout the parent and professional community. There are a number of myths regarding intensive behavioral treatment approaches, such as applied behavioral analysis (ABA). For example, some believe that ABA makes children robotic, ABA-learned skills do not generalize, and children with high-functioning autism do not benefit from ABA. In this article, we have chosen to focus on the myth that intensive behavioral intervention provides benefit only to young children with autism.

The Evidence

As a complex disorder involving cognitive function, autism has been showered in claims of cures and unproven methods of intervention. Behavioral techniques have been used very effectively to control weight, aid in smoking cessation, and manage exercise programs. These are just a few examples of areas of behavioral change that most "normal" adults attempt at least once or twice in their lives.

Additional evidence for the effectiveness of behavioral treatment comes from many years of scientific studies of other psychological conditions. For example, behavioral treatments of varying intensity have been shown to be effective as standalone or adjunctive techniques for anxiety disorders, ^{1, 2} mood disorders, ³ and many other psychological conditions.

Continued benefit from behavior therapy in adulthood also is consistent with changing conceptualizations of brain development with age. It was previously assumed that the brain was no longer changing after adolescence. However, brain circuits continue to be modified throughout the lifespan. In particular, the frontal lobe of the brain, which is responsible for the most complex cognitive functions (planning, organizing, directing attention, etc.) and is impaired in autism, is still growing and changing dramatically well into the late 20s and early 30s. ^4-6 These data suggest that behavioral approaches may be useful for not just temporarily changing autism symptoms but also for providing lasting changes to brain circuitry that persist throughout life.

Finally, although we believe that anecdotal evidence should not be considered as a primary means for determining the viability of a treatment, growing anecdotal evidence is derived from ongoing adult behavioral treatment programs throughout the country. In many treatment centers, young adults with autism who did not receive early intensive behavioral intervention have benefited tremendously from intensive behavioral intervention in adulthood. Some of these adults have achieved goals that included part- or full-time employment in jobs in the community and semi-independent living that would not have been attempted prior to treatment.

Ultimately, the proof is in the pudding. Research concerning intensive behavioral intervention has historically focused on only the reduction of negative or harmful behaviors. ⁷ Greater research attention is needed toward behavioral treatment focused on fostering positive, functional behaviors in adults.

The How

Behavioral techniques used in most areas of life involve targeting positive behaviors to foster, negative behaviors to reduce, goal setting, rewards, or positive reinforcement of desired behavior. Treatment of adults with autism is no different. They derive significant benefit from goal setting and rewards for appropriate behavior. Below are basic suggestions for developing a behavioral intervention program for adults.

Behavioral intervention in adults should be functional, addressing skills that matter for the individual's lifelong functioning.
Targeted skills should be appropriate to the adults' assessed level. In higher-functioning adults, treatment may involve complex social skills and theory-of-mind teaching. It may begin with discrete trial teaching for a brief period but quickly be transferred to real-world applications. In lower-functioning adults, treatment may be more focused on functional skills and promoting basic elements of social interaction. Time-intensive, discrete trial teaching may be necessary for longer periods of time.
Generalization is always the ultimate goal. Targeting skills is most useful if the adult can use those skills in a variety of situations. For example, adults learning to place an order in a restaurant may begin through discrete teaching of the individual steps, but then proceed to a mock restaurant environment. Later these skills can be transferred to a local restaurant and then finally to a number of different locations in the adult's daily living environment using least restrictive prompting.
Treatment should respect the interests and desires of the adult. Many children with and without autism do not want to do things that parents force them to do for their ultimate benefit. However, adults with autism have long developed preferences that should be respected. It is important that caregivers; other stakeholders; and, if possible, the adult with autism communicate with the professionals conducting treatment to alert them to these situations, become proficient at preference assessment, and develop collaborative treatment plans.

The Where

There is currently a lack of appropriate behavioral intervention services for adults with autism in most communities in the country. In our experience, the services that are available tend to be costly, do not provide the level of expertise or intensity that would be most helpful to the adult, or do not provide for adequate generalization of skill teaching.

This situation must change as the current prevalence estimate for autism (1 in 150) indicates that this will be a major public health problem in the near future. It is important that parents and other stakeholders educate legislators and other community decision makers about the needs and effectiveness of behavior therapy for adults with autism. Ultimately, we must all become advocates to attempt to change the system.

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