Can we have early behavioural intervention for all children with disabilities in the UK who need it?

I’ve already written a blog recently about some thoughts emerging from the campaign ABA4All [https://www.facebook.com/ABAforallchildren]. This new blog is partly in support of this campaign, and partly to build on arguments from previous blogs over the past couple of years.

ABA (Applied Behaviour Analysis) is a dirty “word”

Let’s face it, the term ABA carries an awful lot of baggage. People think it is an intervention/treatment in itself (rather than an applied science), think it is about supporting children with autism, and ABA is also associated with traumatic experiences for many professionals and policy makers. By traumatic experiences, I mean being subjected to sometimes fundamentalist proponents of ABA who insist that things must be done in particular ways because “that’s what the evidence says” and also argue that ABA “has the best evidence in the field of autism”. 

I think we should all be using more precise terms here. So, let’s stop talking about ABA at all. Instead, let’s use labels that clearly say something about the focus of any intervention/treatment approach. As an example, the approach that combines ABA understanding and methods with a strong focus on values and attention to the person’s context to “treat” challenging behaviours in people with developmental disabilities is called Positive Behaviour(al) Support (PBS). Everyone loves PBS. It sounds nice, and it carries little of the negative baggage of “ABA”. However, PBS is simply good ABA. An ABA treatment/intervention approach or package has been developed to make a positive difference to the lives of people with developmental disabilities. When we talk about evidence based treatment/intervention and best practice working with individuals whose behaviour challenges, we don’t say that they are receiving ABA. It would make little sense to do so, because “ABA” does not communicate the specificity that is PBS. We just say they are receiving a PBS intervention or service.

The same case applies to early intervention for children with significant disabilities (intellectual disability, any number of syndromes associated with intellectual disability, and autism). I’m suggesting that we use a term that makes clearer what the treatment/intervention is. My suggestion is Early Behavioural Intervention (EBI). This term is not new – we and others have used it in international peer review journals when reporting on research studies. EBI can be used to refer to high quality support using behavioural principles and methods (i.e., drawn from the science and practice of ABA) delivered explicitly with early intervention in mind.

EBI, I would argue, refers to a number of intervention/treatment approaches that have behavioural methods at their core but emphasise different aspects of teaching methodology and also different settings in which intervention/treatment takes place. A non-exhaustive list would include: the Lovaas method, Discrete Trial Training, “ABA”, Pivotal Response Training, Verbal Behaviour, Natural Environment Teaching/Training, the LEAP model (from the USA – in schools), CABAS schools, and the Early Start Denver Model.

Why not “Intensive”?

Many research outcome studies in the field of autism have used the term Early Intensive Behavioural Intervention. The intensive part really emerges from the earliest evaluation of an EBI approach in autism by Lovaas. Lovaas’ treatment study published in 1987 compared a 40 hours per week intensive EBI approach, to a lower intensity (10 hours per week) model, and a control group who did not receive either treatment/intervention. Now, the 40 hours per week group of children did much better than either of the other two groups and so the argument for Intensity was born.

There are, however, two problems with using the Lovaas study to support an argument that EBI MUST be intensive to be effective. First, intensity was not manipulated experimentally – children were not allocated randomly to one of the treatment conditions. So, the groups could have differed on some other variable that explained the difference in outcomes (or at least some of the difference). Second, the 10 hours per week group differed in other key ways to the 40 hours per week group. These included: some treatment procedures could not be delivered to the 10 hours group because of lack of resources/staffing time, more other interventions were also used alongside the 10 hours, and the children were slightly older.

A second argument is that very positive outcomes for children with autism and children with an intellectual disability have been seen in studies where lower numbers of hours have been delivered (e.g., 15 hours and fewer). A third argument “against” intensity is the results from our large scale analysis of hundreds of children with autism who received EBI as a part of research evaluation studies around the world [see http://profhastings.blogspot.co.uk/2013/04/the-most-significant-and-original-data.html]. When we looked at variables associated with outcomes for the children, higher intensity (number of hours per week) did predict better outcomes. However, intensity explained only a small amount of outcome. Something else (or some combination of other factors) explains an awful lot more!

The argument FOR intensity in early intervention is an international consensus about the fact that any early intervention for children with significant disabilities (not specific to EBI at all) ought to be intensive. The assumption is that a higher “dose” will lead to more cumulative learning and so better outcomes overall.

Coming back to the UK again, a further reason for arguing for EBI and not EIBI is that 40 hours per week is completely unrealistic. The more we push for this, and it clearly cannot be afforded now or probably ever, the more that the wider population of children with significant disabilities will lose out to the small number of children who are able to access this sort of intensive intervention.

Quality delivery by experts

It is not the case that just anyone can deliver high quality and effective EBI. All of the existing research evaluation studies (including all of the “treatments” I claimed are EBI –PRT, ESDM etc etc.), tested treatments/interventions delivered by highly trained and supervised individuals. A couple of hours of training generally in “ABA” or an eclectic mishmash of approaches is not the same as what has been delivered in research studies and evaluated as evidence-based.

In the UK, hundreds of students have now graduated from post-graduate University courses that teach the theory and practice of ABA. Universities delivering, or who have delivered, these courses include: Bangor, Swansea, Cardiff, Kent (Tizard Centre), South Wales, Queens University Belfast, and Ulster. Of course, individual practitioners need additional training in particular intervention approaches (like EBI) and to understand the context in which they will be working. They also need ongoing supervision (just like any health, social care, or education professional in the UK). However, the point is that trusted and respected UK higher education institutions already have training courses that can support the experts who will design and deliver EBI services. More training courses, run by these experts, are also probably needed in the UK for staff of various kinds who will do most of the hands-on delivery of EBI (e.g., early years staff, teaching assistants).

EBI can be delivered effectively by specially trained and supervised professionals. UK state funded Universities can be trusted to help with this task of workforce training and development.

EBI for every child with significant disabilities in the UK

Here’s where we return to the ABA4All campaign. A central pillar of ABA4All’s work is parent choice. Even if you do not believe that EBI works better than other approaches typically available to children with autism and with other disabilities, it is a respected evidence-based approach delivered by well-trained professionals in the UK. There is every reason to offer parents EBI, or to make sure they are able to choose EBI for their child and family. Not everyone will want to choose EBI and that’s fine. At the moment though, ABA4All argue that parents and children are explicitly denied EBI. I agree.

ABA4All also campaign on the basis that what I’m calling EBI should be a choice that is available universally in the UK, so for all children who may need this boost early in life. Again, I agree. I think this does have some implications. The main one is that 40 hours per week is not going to be the answer when it comes to universal choice/provision. In any case, the key argument I make above is for quality and not necessarily quantity. So, what might be affordable – what existing funding mechanisms might be extended to open up the choice for parents of being able to have EBI for their child? How can we make sure that enough people are trained, properly supervised, and properly quality-assured to make this happen? The fact that universal availability is a challenge – to scale-up from the current provision across the UK – is not a reason to do nothing.

I also suggest that we must campaign outside of the autism box. Yes, children with autism can benefit from EBI, we have plenty of data to show that, and many parents want EBI for their young children with autism. However, there is nothing really autism-special about EBI. With only very minor changes, the model works very well for children with intellectual/learning disabilities. All of those children and their parents need the choice of EBI to maximise their early life chances.

Parental choice and the relevance of behavioural methods for teaching skills to children with significant disabilities also extend beyond early intervention. Older children desperately need skilled behavioural practitioners supporting them at home, and in mainstream and special education settings. Let’s not forget these children and their families. It is important to start somewhere though, and I think I have to agree that winning a battle about EBI may be the best way to establish a beachhead. 

Good luck to ABA4All.