Document 3 from FOI 23.24 1400 Disclosure log documents.pdf

link to page 1 link to page 1 link to page 2 link to page 2 link to page 3 link to page 4

FOI 23/24- 1400
Research paper
DOCUMENT 3
OFFICIAL
For Internal Use Only
Applied Behaviour Analysis for adults with ASD
The content of this document is OFFICIAL.
Please note:
The research and literature reviews collated by our TAB Research Team are not to be shared
external to the Branch. These are for internal TAB use only and are intended to assist our
advisors with their reasonable and necessary decision-making.
Delegates have access to a wide variety of comprehensive guidance material. If Delegates
require further information on access or planning matters, they are to call the TAPS line for
advice.
The Research Team are unable to ensure that the information listed below provides an
accurate & up-to-date snapshot of these matters
Research question: Is there any research evidence that ABA therapy is effective in the
treatment of ASD in adults?
Date: 14/2/2022
Requestor: Adam Lucht
Endorsed by: Tom Duggan
Researcher: Aaron Harrison
Cleared by: Aaron Harrison
1.
Contents
Applied Behaviour Analysis for adults with ASD ........................................................................ 1
1.
Contents ....................................................................................................................... 1
2.
Summary ...................................................................................................................... 2
3.
Evidence for ABA in adults ........................................................................................... 2
4.
Duration and intensity of behavioural intervention ........................................................ 3
5.
References ................................................................................................................... 4
ABA for adults with ASD
Page 1 of 6
OFFICIAL
Page 26 of 125

FOI 23/24- 1400
Research paper
OFFICIAL
For Internal Use Only
2. Summary
There is evidence that interventions based on Applied Behaviour Analysis (ABA) can be
effective in improving skills and outcomes and reducing concerning behaviour for older
adolescents and young adults with autism. However, the evidence base is small and the
literature mostly reports on single subject case studies or otherwise small sample studies.
There is a lack of consensus about effective and ethical intensity of behavioural interventions.
ABA is a discipline which incorporates many different techniques and treatment protocols. It is
possible that different ABA interventions would require different frequency and duration of
supports. No studies were found that focussed on intensive ABA for older teenagers or adults.
The focus of this paper is on recent published research which summarises and reviews
existing research. Considering the timeframe of this paper and the breadth of literature, it
should be noted that there may be further relevant research we have not examined.
3. Evidence for ABA in adults
Research on interventions for older adolescents and young adults with autism is scarce. Most
of the research on ABA focusses on younger children. Results of research on younger children
may not generalise for adults (Shattuck et al, 2020; Howlin, 2021; Lord et al, 2022; Rodriguez
et al, 2022). Straiton et al (2021) conducted a survey study including 97 ABA providers that
related to parent training as a component of ABA practice for people with autism under 21.
They note that very few ABA providers were aware of evidence-based strategies for
incorporating parent training in their program. Lord et al (2022) summarise the evidence:
Behavioural programmes for adults with autism have been described for many years,
although few are randomised controlled trials and many involve individuals with more
severe intellectual disabilities. The use of behavioural approaches is also controversial
among some neurodiversity advocates (Lord et al, 2022, p.290).
Much of the research on autism in adulthood focusses on life-stage outcomes rather than
specific interventions (Mason et al, 2021; Howlin, 2021). Much of the research on use of
behavioural interventions in adults with autism focusses on ethical issues and describes the
controversy around long term use of ABA (Sandoval-Norton et al, 2019; Gorycki et al, 2020;
Shkedy et al 2021).
Evidence-based behavioural interventions identified by Steinbrenner et al (2020) for 15-22
year olds include antecedent-based interventions, behavioural momentum intervention,
differential reinforcement, discrete trial training, extinction, functional behavioural assessment,
modelling, prompting, reinforcement, response interruption/reintegration, self-management,
task analysis, video modelling, and visual supports. These interventions may make up an ABA
program. It is worth noting that, for Steinbrenner et al, an intervention counts as evidence-
based if it has support from either:

ABA for adults with ASD
Page 2 of 6
OFFICIAL
Page 27 of 125

FOI 23/24- 1400
Research paper
OFFICIAL
For Internal Use Only
•  two high quality group design studies conducted by at least two different researchers
or research groups
•  five high quality single case design studies conducted by three different investigators
or research groups and having a total of at least 20 participants across studies
•  one high quality group design study and at least three high quality single case
design studies conducted by at least two different investigators or research groups.
This approach to evidence-based practice is challenged in the literature (Donovan et al, 2020;
Lord et al, 2022). For instance, the Steinbrenner et al approach means that some practices
may count as evidence-based even if they have only a small number of uncontrolled studies
supporting them and even if very few subjects were involved in the intervention.
In their narrative review, Rodriguez et al (2022) provide more detail about some behavioural
interventions they consider efficacious for adults. These include self-management, prompting,
video modelling, visual supports, task analysis, behavioural skills training, and functional
communication training. The authors note that for all these interventions there is minimal adult
focussed research. Where evidence for efficacy in adult populations exists, it is usually based
on single subject case studies or other small sample study designs. One recent systematic
review found moderate to strong evidence that functional communication training can reduce
challenging behaviours in adults with autism (Gregori et al, 2020). However, this was based on
only 8 participants across 8 single case studies. Another recent study found behavioural skills
training improved social and conversation skills for 6 adults with autism when delivered in a
group setting (Ryan et al, 2019).
Theoretically, many of the principles of ABA should work for all age groups. For example,
reinforcement may encourage target behaviour regardless of age group. However, effect size
may be different and different skill areas may be targeted (e.g. community independence,
vocational training) for older adults, young adults and adolescents. Also, there may be some
issues of implementation. For example, Rodriguez et al (2020) note that removing
reinforcement of undesirable behaviours can result in increases in aggression for up to 50% of
subjects. For adults with aggressive behaviours this can pose a significant safety risk
(Manente et al, 2010).
4.  Duration and intensity of behavioural intervention
There is a lack of consensus on the appropriate intensity and duration of behavioural
interventions. Gerhardt et al (2022) suggest it is a myth that adolescents and young adults
would no longer benefit from intensive ABA. However, while the authors cite evidence showing
ABA may be effective for adolescents and young adults, they do not provide evidence for a
high intensity of support. With respect to early intensive behavioural intervention, Leaf et al
(2022) state that intervention is usually concluded prior to school age, though if a child still
requires support then intervention should continue into school age:

ABA for adults with ASD
Page 3 of 6
OFFICIAL
Page 28 of 125

FOI 23/24- 1400
Research paper
OFFICIAL
For Internal Use Only
Although the average may be 3 years, research has shown that a successful duration
can be anywhere between 6 and 36 months. Like the intensity of intervention, the
duration of intervention must be individualized to meet the needs of the individual
learner (Leaf et al, 2022, p.254).
In contrast, the recent Lancet Commission on the future of care and clinical research in autism
report states that the intensive ABA approach:
as originally implemented, has little support from well-designed randomised controlled
trials. However, it has been modified over the past few decades to be more naturalistic
and developmentally appropriate, often with lower-intensity delivery and greater
emphasis on the child as an active partner in communication. In addition, other studies
have focused on teaching parents to support the child in the development of early
communication and social interaction (Lord et al, 2022, pp.278-279).
Shkedy et al (2021) argue there is no research showing the effectiveness of ABA for people
who have received treatment over 5, 10 or 15 years (also, Donovan et al, 2020). While the
appropriate intensity and duration of support is in dispute, Lord et al maintain there is evidence
that behavioural intervention can improve cognitive and emotional self-regulation and
reduction in social difficulties for older children and young adults. They continue:
As for other chronic and enduring health conditions, one-off, time-limited interventions
will not be sufficient to enable long-term change for most people with autism. Instead, a
developmentally sequenced series of staged and personalised interventions will be
required for each individual, according to their developmental stage, profile of strengths
and needs, and co-occurring conditions (Lord et al, 2022, pp.279-280).
The recommendation for a ‘staged’ service implies that the least intensive service is trialled to
determine what the participant’s needs are.
5.  References
Donovan, M.P. (2020). The Department of Defense Comprehensive Autism Care
Demonstration Annual Report. Report to the Committees on Armed Services of the
Senate and House of Representatives. https://altteaching.org/wp-
content/uploads/2020/10/Annual-Report-on-Autism-Care-June-2020.pdf?x78693
Gerhardt, P. F., Bahry, S N, Mason, B., Sasaki Solis, M. (2022). On Predicting the Future:
recommendations for the field of ABA in supporting adults with ASD. In Leaf, J. B.,
Cihon, J. H., Ferguson, J. L., & Gerhardt, P. F. (Eds.). Handbook of quality of life for
individuals with autism spectrum disorder (1st ed.). Springer Nature.
Gorycki, K. A., Ruppel, P. R., & Zane, T. (2020). Is long-term ABA therapy abusive: A
response to Sandoval-Norton and Shkedy. Cogent Psychology, 7(1), 1823615.
https://doi.org/10.1080/23311908.2020.1823615

ABA for adults with ASD
Page 4 of 6
OFFICIAL
Page 29 of 125

FOI 23/24- 1400
Research paper
OFFICIAL
For Internal Use Only
Gregori, E., Wendt, O., Gerow, S., Peltier, C., Genc-Tosun, D., Lory, C., & Gold, Z. S. (2020).
Functional communication training for adults with autism spectrum disorder: A
systematic review and quality appraisal. Journal of Behavioral Education, 29(1), 42–63.
https://doi.org/10.1007/s10864-019-09339-4
Howlin, P. (2021). Adults with autism: Changes in understanding since DSM-111. Journal of
Autism and Developmental Disorders, 51(12), 4291–4308.
https://doi.org/10.1007/s10803-020-04847-z
Leaf, J. B., Cihon, J. H., Ferguson, J. L. (2022). The Relationship of Early Intensive Behavioral
Intervention and Adulthood for Autistics/Individuals Diagnosed with Autism Spectrum
Disorder. In Leaf, J. B., Cihon, J. H., Ferguson, J. L., & Gerhardt, P. F. (Eds.).
Handbook of quality of life for individuals with autism spectrum disorder (1st ed.).
Springer Nature.
Lord, C., Charman, T., Havdahl, A., Carbone, P., Anagnostou, E., Boyd, B., Carr, T., de Vries,
P. J., Dissanayake, C., Divan, G., Freitag, C. M., Gotelli, M. M., Kasari, C., Knapp, M.,
Mundy, P., Plank, A., Scahill, L., Servili, C., Shattuck, P., … McCauley, J. B. (2022).
The Lancet Commission on the future of care and clinical research in autism. Lancet,
399(10321), 271–334. https://doi.org/10.1016/S0140-6736(21)01541-5
Manente, C. J., Maraventano, J. C., LaRue, R. H., Delmolino, L., & Sloan, D. (2010). Effective
behavioral intervention for adults on the autism spectrum: Best practices in functional
assessment and treatment development. The Behavior Analyst Today, 11(1), 36–48.
https://doi.org/10.1037/h0100687
Mason, D., Capp, S. J., Stewart, G. R., Kempton, M. J., Glaser, K., Howlin, P., & Happé, F.
(2021). A meta-analysis of outcome studies of autistic adults: Quantifying effect size,
quality, and meta-regression. Journal of Autism and Developmental Disorders, 51(9),
3165–3179. https://doi.org/10.1007/s10803-020-04763-2
Rodriguez, k. A., Foreman, S., & Davis, K. (2022). Applied Behavior Analysis: an overview of
ABA-based autism services for adults. In Leaf, J. B., Cihon, J. H., Ferguson, J. L., &
Gerhardt, P. F. (Eds.). Handbook of quality of life for individuals with autism spectrum
disorder (1st ed.). Springer Nature.
Ryan, G., Brady, S., Holloway, J., & Lydon, H. (2019). Increasing appropriate conversation
skills using a behavioral skills training package for adults with intellectual disability and
autism spectrum disorder. Journal of Intellectual Disabilities: JOID, 23(4), 567–580.
https://doi.org/10.1177/1744629517750744
Sandoval-Norton, A. H., Shkedy, G., & Shkedy, D. (2019). How much compliance is too much
compliance: Is long-term ABA therapy abuse? Cogent Psychology, 6(1), 1641258.
https://doi.org/10.1080/23311908.2019.1641258

ABA for adults with ASD
Page 5 of 6
OFFICIAL
Page 30 of 125

FOI 23/24- 1400
Research paper
OFFICIAL
For Internal Use Only
Shattuck, P. T., Garfield, T., Roux, A. M., Rast, J. E., Anderson, K., Hassrick, E. M., & Kuo, A.
(2020). Services for adults with autism spectrum disorder: A systems perspective.
Current Psychiatry Reports, 22(3), 13. https://doi.org/10.1007/s11920-020-1136-7
Shkedy, G., Shkedy, D., & Sandoval-Norton, A. H. (2021). Long-term ABA therapy is abusive:
A response to Gorycki, Ruppel, and Zane. Advances in Neurodevelopmental Disorders,
5(2), 126–134. https://doi.org/10.1007/s41252-021-00201-1
Steinbrenner, J. R., Hume, K., Odom, S. L., Morin, K. L., Nowell, S. W., Tomaszewski, B.,
Szendrey, S., McIntyre, N. S., Yücesoy-Özkan, S., & Savage, M. N. (2020). Evidence-
based practices for children, youth, and young adults with Autism. The University of
North Carolina at Chapel Hill, Frank Porter Graham Child Development Institute,
National Clearinghouse on Autism Evidence and Practice Review Team.

ABA for adults with ASD
Page 6 of 6
OFFICIAL
Page 31 of 125