Critical outcomes for behavioral analytic interventions

The importance of outcomes has received increasing attention in healthcare. With the advent of value-based care, measures of quality focus on outcomes that matter to the individual (i.e., patient in healthcare, client in behavior analysis). The objective of healthcare outcomes, therefore, resides with improvements in a patient's health status. Outcomes serve as the endpoints of care.

Behavior analysis.

The application of behavior analysis (ABA, when applied to people) has increasingly moved from psychology and education to healthcare. It follows that behavior analysis shares a goal with other disciplines in medicine, namely, to improve the patient’s (or client’s) behavioral status.

Indeed, the term “behavioral health” has become popular, and refers to the impact behavior has on physical health as well as psychological well-being. ABA has much to offer in regard to behavioral health. The outcomes or endpoints for behavior analysis can vary and will relate to the client receiving services.

Measuring, reporting, and comparing behavioral outcomes holds great importance for the client, behavior analyst, and stakeholders. The triple aim of healthcare improvement further illustrates the weighty significance of behavioral outcomes.

1. Improve care and the client experience.

2. Improve the health of populations.

3. Reduce the cost of healthcare.

All of the previously listed healthcare outcomes translate to behavior analysis, as well.

1. Improve the client experience during therapy and apply socially valid interventions.

2. Improve the behavior of individuals, which also enhances societal welfare.

3. Reduce the cost of behavior analytic interventions.

As well as one additional outcome:

4. Reduce burnout of behavior analysts and associated professionals.

The following list suggests several prominent outcomes for behavior analysis. The field has made tremendous strides in each of the described outcomes.

Behavioral outcomes.

?Reduction of challenging behavior. The reduction of challenging behavior, sometimes referred to as problem or maladaptive behavior, represents an important result. For example, aggression commonly co-occurs with autism spectrum disorder (ASD) (Matson & Cervantes, 2014). Aggression can limit opportunities for people with ASD in regards to accessing school and vocational settings (Mazurek, Kanne, & Wodka, 2013).

?Behavior analysis uses procedures based on principles of behavior. The behavior change procedures most often result from an analysis of prevailing contingencies for the client. For instance, hand biting functioning mostly for escape would prompt a behavior analyst to craft a program with a replacement behavior. The plan could call for employing a reductive procedure for one behavior, and a growth or reinforcement program for another. The literature for function-based interventions and procedures built upon individualized and compassionate procedures serves as the hallmark for behavior analytic treatment.

Verbal behavior. Verbal behavior refers to a special type of behavior that covers what other disciplines would classify as language or communication. Verbal behavior has a special condition in that another person mediates its reinforcement. An example of mediated reinforcement occurs when a child says “dada” in the presence of their father. The father then says “Hi, precious.” The father mediated the reinforcement by delivering it. A child that squeezes a doll which activates the doll making an automatic sound did not receive mediated reinforcement from another person.?

Verbal behavior contains verbal operants, which means that verbal behavior operates on the environment. A “mand,’ for example, represents a verbal operant. Understanding how a man works or operates in the environment allows a behavior analyst to recognize the cause of certain behavioral problems. Indeed, a recent summary of verbal behavior applications for people with developmental disabilities found numerous benefits for the functional analysis of language (Carnett et al., 2019).?

Social behavior. When people interact with one another, social behavior broadly captures such connections. Children display social behavior when they play, greet one another, or share a snack. Many children with disabilities and learning differences lack, or have delayed, social behaviors. A study examining social skills and behavior of four groups of children with disabilities found that children with attention-deficit hyperactivity disorder had significantly more challenging behaviors and less developed social skills (Fussell et al., 2005).

Behavior analysis has an extensive history of helping develop prosocial behaviors and social skills. Focused interventions and comprehensive programs exist which speak to social behavior growth. The Good Behavior Game (GBC), for instance, focuses on creating positive learning environments in schools. GBC uses a behavioral approach to increase positive social behaviors and decrease disruptive and problematic social behaviors.

Adaptive behavior. In some children, adaptive behavior defines the disability. A qualified professional would diagnose an intellectual disability when a child has significant limitations with both intellectual functioning and adaptive behavior. Adaptive behavior encompasses skills necessary for people to function independently in different settings such as home, school, or the community. Adaptive behavior can include activities of daily life (e.g., dressing, bathing), personal health and safety, and engaging in leisure and work activities (Price et al., 2017).

A number of studies have demonstrated how the systematic and intensive application of behavior for people with autism spectrum disorder maintains over long periods of time. Additionally, the research shows a reduced need for special services or supports in school and an increased likelihood of independent living later in life (Linstead et al., 2017).

Foundational learning behavior. Harlow (1949) described “learning set formation” and received credit for the “learning to learn” concept. Learning to learn happens when a child has the ability to quickly acquire, understand, and transfer new knowledge or skills to other skills or contexts. Behavior analysis would characterize such behavior as the result of foundational learning behavior.

Foundational learning behaviors incorporate behaviors such as imitation, matching, joint attention, and other verbal behavior repertoires (e.g., mands, tacts, echoics, listener skills). The acquisition of important foundational learning behaviors appear in many important assessments, programs, and books for teaching early learners (e.g., Verbal Behavior Milestones Assessment and Placement Program, Assessment of Basic Language and Learning Skills, Peak Relational Training). Foundational learning behaviors’ research base and teaching methods also appear in most behavior analytic textbooks (Cooper et al., 2020; Mayer et al., 2019).

Outcomes and Individualization.

?The previously listed outcomes represent several prominent results that occur with the application of ABA. Applied behavior analysis addresses the needs of people with disabilities and learning differences. Through evidence and advocacy, ABA has become medically necessary for some people with ASD. Therefore, many of the previously listed outcomes concentrate on behavioral reduction and the growth of skills needed for helping one learn faster and achieve their potential.

References.

Carnett, A., Raulston, T. J. & Charpentier, J. (2019). The Application of Skinner’s Analysis of Verbal Behavior for Teaching Communication Skills to Persons with Developmental Disabilities. Current Developmental Disorders Report, 6, 131-137. https://doi.org/10.1007/s40474-019-00170-0

Cooper, J. O., Heron, T. E., & Heward, W. L. (2020). Applied behavior analysis (3rd ed.). Hoboken, NJ: Pearson Education.

Fussell, J. J., Macias, M. M., & Saylor, C. F. (2005). Social skills and behavior problems in children with disabilities with and without siblings. Child Psychiatry and Human Development, 36(2), 227-41. https://doi.org/10.1007/s10578-005-4185-6

Harlow, H. F. (1949). The formation of learning sets. Psychological Review, 56, 51-65. https://doi.org/10.1037/h0062474

Linstead, E., Dixon, D. R., French, R., Granpeesheh, D., Adams, H., German, R., Powell, A., Stevens, E., Tarbox, J., & Kornack J. (2017). Intensity and Learning Outcomes in the Treatment of Children with Autism Spectrum Disorder. Behavior Modification, 41(2), 229-252. https://doi.org/10.1177/0145445516667059

Matson, J. L., & Cervantes, P. E., (2014). Assessing aggression in persons with autism spectrum disorders: An overview. Research in Developmental Disabilities, 35(12), 3269-3275. https://doi.org/10.1016/j.ridd.2014.08.004

Mayer, G. R., Sulzer-Azaroff, B., & Wallace, M. (2019). Behavior analysis for lasting change (4th ed.). Sloan.

Mazurek, M.O., Kanne, S.M., & Wodka, E.L. (2013). Physical aggression in children and adolescents with autism spectrum disorders. Research in Autism Spectrum Disorders, 7, 455-465. https://doi.org/10.1016/j.rasd.2012.11.004

Price, J. A., Morris, Z. A., & Costello, S. (2018). The Application of Adaptive Behaviour Models: A Systematic Review. Behavioral sciences (Basel, Switzerland), 8(1), 11. https://doi.org/10.3390/bs8010011