Running head: EARLY ABA PREDICTING EXPRESSIVE LANGUAGE SKILLS
Early Applied Behavior Analysis Intervention predicting Expressive Language Skills for
Children with Autism
Reina Valdez
Kaplan University
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Abstract
The purpose of this study is to document the importance and effectiveness of early
Applied Behavior Analysis (ABA) intervention in regards to expressive language. Parents
and caregivers of children with Autism Spectrum Disorder make the mistake of
postponing ABA therapy until later childhood, which causes irreversible damage in the
acquisition of expressive language skills. I aim to find a significant difference between
children who started ABA therapy before the age of four and children who started ABA
therapy after the age of eight. This investigation would raise parental awareness when
their child receives a diagnosis of ADS. In order to demonstrate the importance and
effectiveness or early ABA intervention, 60 children with ASD would be recruited from
three scholarly institutions. 20 children who received intervention before the age of 4, 20
children who received intervention between (4-8 years old), and 20 other children aged 8
years old who have never received ABA intervention. Expressive language skills would
be measured by using the Assessment of Basic Language and Learning Skills (ABLLSR). This assessment shows that there is a significant difference in expressive language
improvements for children who received early ABA therapy compared to children who
received ABA in late childhood.
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Early ABA Intervention Predicting Expressive Language Skills
Autism Spectrum Disorder (ASD) is defined as a group of developmental
conditions characterized by developmental delay, impaired communication skills, lack of
interest, and stereotyped behaviors (American Psychiatric Association, 2018). Among
children with autism, early ABA intervention has become they key to improve
communication skills, social skills, and motor imitation. Early detection and intervention
enhance language development by decreasing developmental delay (Suma, Adamson,
Bakeman, Robins, & Abrams, 2016) after diagnosis. Delaying immediate intervention has
irreversible effects in skills acquisition (Gulsrud, Hellemann, Freman, & Kasari, 2014)
during brain development. The improvement of communication skills among children
with ASD is the main concern for some parents (Suma, et al. 2016) and caregivers since
they believe that the children will be incapable of addressing their own needs. However,
targeting expressive language delays during critical periods is essential to promote
independence (Vivanti & Dissanayake, 2016) for an atypical child. The ability to express
physiological needs such as hunger and thirst are expressed in early childhood in children
receiving early ABA therapy (Gulsrud et al. 2014). This study is designed to address the
effectiveness of early ABA intervention to raise parental awareness of immediate
enrollment in ABA therapy after diagnosis. I asked whether early ABA intervention
would promote better outcomes in expressive language skills than late intervention. In
like manner, I hypothesize that there is a significant difference in expressive language
improvements for children who received early ABA therapy compared to children who
received ABA in late childhood.
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Applied Behavior Analysis (ABA) is defined as a science to study human
behavior for children with developmental disabilities, especially with Autism Spectrum
Disorder (Baer, Wolf, & Risley, 1968). There is a controversy among parents and
caregivers of children with ASD. They are constantly debating if ABA therapy would
have a positive effect (Koegel L., Koegel R., Ashbaugh, & Bradshaw, 2014) in expressive
language skills. By not knowing the importance and effectiveness of early intervention,
parents are prominent to make the mistake of postponing ABA therapy until late
childhood. Hence, parents and caregivers have to be aware that expressive language skills
improve significantly when children begin ABA therapy followed by the diagnosis of
ASD (Suma, et al. 2016). In general, early ABA therapy provides an operant
methodology discovered by Charles Ferster and Marian DeMyer to prove that children
with ASD are able to learn new skills by using positive and negative reinforcement
(Schreibman et al., 2015). The National Institute of Mental Health has determined that
typical symptoms can be recognized at the age of two. Therefore, early intervention could
begin at the time of diagnosis. Early therapy is beneficial for individuals with ASD since
it shapes adaptive and maladaptive behaviors (Vivanti & Dissanayake, 2016) by
promoting the development of daily living skills and learning skills. Even though there
are several studies regarding the effectiveness and impotence of early ABA invention, I
asked if expressive language for children with autism improve with early intervention.
Thus, my hypothesis states that there is a significant difference in expressive language
between children who received early ABA therapy and children who received late
intervention.
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Autism speaks (2018) explains that one in sixty eight children are diagnosed with ASD;
however, after diagnosis some parents and caregivers decide to keep their children at
home to avoid financial costs of ABA therapy (Gibson, 2017), which decreases a possible
catch up in expressive language (Gulsrud et al. 2014) skills during critical periods.
This study focuses on investigating how expressive language differs in children
that received early ABA therapy and children who received late ABA therapy. By
understanding the effectiveness of early ABA intervention, parents and caregivers would
immediately enroll their children into an early intervention program to enhance
expressive language skills. It is important that the parents are aware of possible
permanent delays (Suma, et al. 2016) in expressive language if the child does not begin
therapy once is diagnosed. A study by Koegel L. et al. (2014) discusses that early
intervention decreases severe impairments in speech acquisition. More than 90% of
individuals who received early intervention (Koegel L. et al 2014) become verbal; thus,
intervention after pre-school years (Koegel, 2000) decreases the likelihood to produce
speech in children intervened after the age of 5-years (Koegel, 2000). The study by
Suma, et al. (2016) demonstrated that early ABA intervention promote parent-child
interaction. Researchers hypothesized that the amount of early ABA intervention is
associated with positive changes between parent-child communications (Suma, et al.
2016); therefore, expressive language initiates any type of interaction from child to
parents. For example, if a child is non-verbal, it does not mean that it won’t able to
communicate. Their methodology consisted on recruiting 79 participants to conduct a
longitudinal study. Researchers evaluated 40 boys who meet the inclusion criteria to then
use standardized assessments such as The Mullen Scales of Early Learning (Mullen
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1995) and ADOS (ADOS: Lord et al. 2000) to access language and social skills. They
evaluated children between 18-24 months of age before and after intervention. In my
study, a group participant would be evaluated before and after the investigation to target
significant differences in expressive language development. Their results indicated that
the earlier the therapy the better parent-child interaction (Suma, et al. 2016). My study
deals with the effects of early ABA intervention in expressive language. This is important
to establish a connection between parent and child through expressive language. Early
intervened children are able to reach their needs and to alert other people of what they
want (Suma, et al. 2016).
Another important factor that triggers early intervention to improve expressive
language in children with ASD is social connections. The outstanding study by Gulsrud et
al. (2014) demonstrated that early intervention increases joint attention skills. They
hypothesized that children between 2-5 years of age who participate in treatment develop
pre-linguistics gestures (Gulsrud et al. 2014) to establish social interaction among peers
and parents. Their methodology consisted on sampling mostly boys from preschool (2-5
years old) to elementary school (8-10 years old). They aimed to measure pointing,
showing, and coordinated joint movement (Gulsrud et al. 2014) to determine the
effectiveness of interventions in social communication. Researchers used The Expressive
Vocabulary Test (Williams, 1997) and the Autism Diagnostic Observation Scale (ADOS;
Lord, Rutter, & DiLavore, 1997). They concluded that children in early preschool years
display more pointing and gestures than children between 8-10 years of age. My research
would target specific expressive language skills such as imitation, reading, and
spontaneous vocalization.
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Even though parents and caregivers of children with ASD refuse to put their
children in ABA therapy, another study by Vivanti & Dissanayake (2016) demonstrates
that intervention should be received during early sensitive periods. In this study,
researchers evaluated 32 children aged 18-48 months and other 28 children aged 48-62
months (Vivanti & Dissanyake, 2016). They hypothesized that The Early Start Denver
Model, which is an intervention program, prevents expressive language delays.
Researchers tested two groups of children: group one group being 18-48 months and
group two being 48-62 months (Vivanti & Dissanyake, 2016). Their participants received
intervention 20hrs a week to then be evaluated through parent questionnaires from the
Vineland Adaptive Behavior Scales II (Sporrow et. 2005). Their evaluation showed that
younger children (18-48 months) achieved higher progress in language domains (Vivanti
& Dissanyake, 2016) compared to older children. The study I plan to conduct proposes to
measure expressive language skills though by using the ABLLS-R (J. Partington, 2006)
in order to access eight specific skills under the umbrella of expressive language.
My study is designed to investigate the effectiveness of early ABA intervention in
expressive language. I asked how levels of expressive language differ from children who
received early ABA intervention and children who received late or no intervention. What
do I mean by early or late? Well this study would evaluate three different groups of
children with ASD. Group one (early) would be children who started ABA between 1-4
years old, group 2 (mid-early) are children who started ABA between 4-8 years old, and
finally group 3 is categorized as late for children who start ABA at the age of 8 years old.
This study is important for parents and Behavior Analysts to recognize that children
within the spectrum are able to develop more abilities through behavior intervention.
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When we talk about abilities, we are also refereeing to new skills acquired over time. The
importance of receiving early ABA therapy is to promote independence on basic living
skills (Gulsrud et al. 2014) and to prevent irreversible impairments in expressive
language. In like manner, parents and caregivers have to be aware of the benefits that
early ABA intervention provides to children with autism. After diagnosis, early ABA
therapy decreases severe impairments in speech acquisition (Koegel L. et al 2014). In
addition, parent-child interaction is also derived from expressive language (Suma, et al.
2016) to establish a better understanding between the child and parents. Likewise, social
communication skills are essential to interact with peers and parents (Gulsrud et al.
2014) during developmental years. I wonder how expressive language differs in children
who started ABA in different time periods. The comparisons would raise parental
awareness so parents of children with ASD would not doubt to enroll their children in
ABA therapy regardless financial hardships.
My hypothesis states that there is a significant difference in expressive language
improvements for children who received early ABA therapy compared to children who
received ABA in late childhood. Expressive language would be measured by using the
ABLLS-R assessment to average percentage performance in sections C, E, H, L, J, Q, S,
and I, which corresponds to expressive language development. This hypothesis would
answer the research question by comparing mean score percentages in each section with
different groups. These measures would also allow assessing specific needs that the
children might have. All children with Autism Spectrum Disorder present various levels
of severity and expressive language skills impairments. This study will account for
individual differences by using the Autism Diagnostic Interview-Revised (ADI-R) as the
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study performed by Suma, et al. (2016). This scale would arrange the level of severity.
Overall, this study plans to recruit 60 children with ASD from different scholarly
institutions. 20 children who received ABA before the age of 4, 20 children who received
ABA between 4-8 years of age, and 20 children who are 8 years old and have not
received ABA. I aim to find a significant difference in expressive language among
children who started ABA therapy before 4 years old and children who have not received
ABA therapy at the age of 8 years old. The assessment would be conducted to all groups
in year one. Then, 8 years old children will begin ABA therapy for their first time during
a 13 months period. In year two the ABLLS-R would display if there were a significant
difference between the same groups after 8 years old experienced at least one year of
ABA therapy. As a matter of fact, this research is designed to demonstrate the importance
and effectiveness of early ABA intervention. By studying and assessing different groups
like in previous studies, parents, caregivers, and behavior professionals are aware of
critical periods to enhance expressive language in children with ASD.
Method
In order to investigate the significant difference between children who begin ABA
therapy at an early age and children who begin ABA therapy in late childhood the
following procedure is proposed. The procedure would be performed on children who
have been diagnosed with ASD based on the DMS-5. In addition, ADI-R assessment
would be used to determine the level of severity. Finally, of expressive language would
be accessed through the ABLLS-R standardized assessment.
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Participants
In this study, target population is children with ASD. The sampling method would
be stratified random by selecting sixty children from three institutions. In like manner,
participants will be 60 children aged 8 years old diagnosed with Autism Spectrum
Disorder (ASD) from the state of Florida. Of those, 15 will be girls and 45 will be boys.
All children have to meet the criteria for a diagnosis of ASD based on the Diagnostic and
Statistical Manual of Mental Disorders (DSM-5). In addition, since the range of severity
ranges from 1-3 (DSM-5, 2013) the 60 children will have to be within the category of
level 2 “requiring substantial support” (Autism Speaks, 2018). In this study there will be
more boys than girls since Autism Spectrum Disorder is more common in males than
females. Statistics show that 1 out of 42 boys are diagnosed with ASD whereas 1 out of
189 girls are diagnosed with the disorder (Centers for Disease Control and Prevention,
2017).
Even though the participants have been diagnosed with ASD, the Autism
Diagnostic Interview-Revised (ADI-R) would be used to confirm the level of severity
specifically in communication and language skills. This standardized assessment is not
directly done to the child, instead, the parent or caregiver is the one who responds to the
questions asked by a trained psychiatrist or clinical psychologist. This interview is
important to gain access to the child’s developmental history (ADI-R, 1994) from a
person close to the child. The results of this interview will determine if the participants
meet the criteria for the research. For this particular interview, the scale ranges from 0-3
categorizing “3” as the most abnormal result (ABA-edu, 2017).
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For the purpose of this study, all participants have to be in level 2 in both DSM-5 and
ADI-R.
The 60 children with ASD will be recruited from Palm Beach School for Autism,
Mountaineer School of Autism, and South Florida Autism Charter School. There would
be handouts given to the parents or caregivers of 8 years old children diagnosed with
ASD. The handouts will ask parents/caregivers to volunteer in the study whether their
children have or have not received ABA therapy at some point. They will be asked to
write when did the child started ABA or if they never had ABA therapy. There would be
an incentive of fifty dollars for each volunteer. If they are interested, they will email or
call the contact person assigned in the handout. The study will begin once 20 participants
who received ABA between ages 1-4 are found. In the same context, 20 participants who
received ABA between ages 4-8 and finally 20 participants who have never received
ABA at the age of 8 years old for a total of 60. However, it is possible that parental
reports on the date that children begun ABA therapy would not be accurate. Thus, a
school report would be requested from the institution.
Materials
The tool that will be use is the assessment of Basic Language & Learning Skills
(ABLLS-R). This is an accurate assessment to use in this study because it evaluates all
aspects of child development from birth to twelve years old. The key variables to access
expressive language are imitation, spontaneous vocalizations, and intraverbals. The
results would be analyzed through a one-way ANOVA (Vivanti & Dissanayake, 2016)
after collecting the mean group scores. There are 25 skill areas that allow professionals
such as Behavior Annalists and Psychologists to target concerns in child’s development
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regarding expressive language skills. According J. Partington (2006), this test provides
information of language, social interactions, and motor skills. The ABLLS-R (J.
Partington, 2006) was chosen in this study to specifically evaluate expressive language
skills using the Verbal Behavior method of behavioral analysis created by Dr. B.F Skinner
in 1957 (Special Learning, 2009), which indicate strong validity. Moreover, a pilot study
conducted by J. Partington, A. Bailey, and S. Partington (2016) revealed that the test
provides consistent and reliable results when tested different groups of children in all 25skill areas. A Board Certified Behavior Analyst (BCBA) will perform the ABLLS-R
assessment once the participants meet the inclusion criteria for the study. A BCBA-D or
school Psychologist will witness the BCBA that will perform the assessment; thus, both
professionals have to coincide with the data. To fully conduct the assessment, the
Assessment Kit for ABLLS-R and manual are needed along with an Excel data sheet
outlining the 25 skill areas. The protocol includes detailed information on how to collect
data in specific sections within the ABLLS-R and which materials will be needed to
conduct the assessment. Finally the ABBLS-R will be conducted in the child’s natural
environment, which is their home or where they spend most of their time.
Procedure
An incentive of $50 dollars will be given to the parents who volunteer in the
study. There will be an informed consent outlining the purpose of the study,
confidentiality, privacy, and the right to drop out from the study any time. The researcher
and the BCBA will hand the informed consent to parents of participants. Six Board
Certified Behavior Annalists will be part of the study to perform the ABLLS-R
assessment along with 6 school Psychologists. There is no especial training needed to
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these professionals to conduct the assessment. However, the researcher itself cannot
conduct the assessment unless is a Registered Behavior Technician (RBT) or a BCaBA
supervised by a BCBA.
Sixty children aged 8 years old diagnosed with ASD by the DSM-5 and ADI-R
within level 2 will be divided into the following groups:
Group A will consist of 20 children: 15 boys and 5 girls who started ABA
intervention between1-4 years old.
Group B will consist of 20 children: 15 boys and 5 girls who started ABA
intervention between 4-8 years old.
Group C will consist of 20 children: 15 boys and 5 girls who have not received
early ABA intervention at the age of 8.
Two pairs of professionals would be assigned to each group. Therefore group A will have
a BCBA and a school Psychologist that will perform the ABLLS-R to ten of the twenty
children and the other pair will do the assessment to the other ten children. Groups B and
C will follow the same order. This is a between subjects design consisting of three groups
differing in the age when they started receiving ABA intervention. Since the ABLLS-R
consists of is a 25 skill areas, the data will only be collected on the 8 areas dealing with
expressive language skills.
C – Imitation
E – Vocal Imitation
H – Intraberbals
I – Spontaneous Vocalizations
J – Syntax & Grammar
L – Social Interactions
Q – Reading
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S – Writing
The purpose of only choosing the sections mentioned above is to precisely concentrate on
Expressive Language Skills performance labeled as the outcome variable (OV). The
ABBLS-R will be performed at the participant’s natural environment in the presence of
the parent or caregiver. After one year, the assessment will be conducted to the same
groups; however, group C will now have received one year of ABA intervention and all
children will be nine or about to turn 9 years old.
There results would be debriefed to the parents/ caregivers once both data sheets
(year 1 and year 2) are analyzed. Deception is not necessary since the parents/ caregivers
will be aware of the purpose and procedure at the beginning of the study.
Measures
In this study the predictor variable is time of ABA intervention. It is divided into
three levels. Thus, level 1 is categorized as early for children who started ABA between
1-4. Moreover level 2 is categorized as middle for children who started ABA between 48; finally, level 3 is categorized as late since the children have received ABA for one year
or less. Determining if early ABA intervention improves Expressive Language Skills
proves the validity of this variable. However, there is no much evidence to prove
reliability. By studying three different groups of different ages, it can be determined if
early ABA intervention have a significant effect on expressive language skills.
On the other hand, the outcome variable is average percentage performance in
sections C, E, H, I, L J, Q, S of the ABLLS-R assessment. These sections are meant to
provide information on expressive language skills development. For example, the eight
sections will display the average percentage of groups A, B, and C to determine the
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results in the first and second year. By performing the assessment one more time after
first year, reliability will increase. In addition, targeting specific sections involving
expressive language skills in the ABLLS-R provides high validity to this variable.
The outcome variable is expressive language skills measured by the eight sections
of ABLLS-R that deals with expressive language. Scores would indicate that children
who started ABA before the age of four are able to express their needs and to initiate
spontaneous vocalizations. Therefore, there is a significant difference between children
who started ABA at 8 years old and children who started ABA therapy before four years
old. The findings support my hypothesis and answered my research question.
Ethical Considerations
An essential component of this study is ethical considerations. This study deals
with children with ASD meaning that they are not capable of signing a consent, first due
to their developmental disabilities and second because they are minors. Therefore, a
parent or legal guardian has to sign the informed consent. According to the APA (2017),
Ethic code 8.02, informed consent have to display the benefits, purpose, incentives,
contact for questions, and the right to drop from the study.
Another thing that fits to this study is the qualification of personnel (APA, 2017)
Ethic code 7.02. The researchers are responsible to have well trained professionals to
conduct the assessments. The Board Certified Behavior Analyst and the school
Psychologists recruited for this experiment must provide valid credentials.
Furthermore, in this study there will be no deception since standardized testes will
be performed. Deception is used to wrongly inform the participants of the nature of the
study so they don’t get overwhelmed and affect the results (APA, 2017).
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In the same context, after conducting the study, the parents and caregivers will be
knowledgeable of what the findings indicate and the researchers would restate the
purpose of the research. In case that deception is used with the participants, debriefing
will provide a detailed explanation of the study even including the purpose of deception
(APA, 2017).
Finally, when reporting the results, researchers have to be completely honest
about what was found. If the findings opposed the hypothesis (Early ABA Intervention
Increases Expressive Language Skills) investigators must report whatever the findings
are. An alteration to the results is unethical; thus, false statements should be avoided
(APA, 2017). If the results indicate that there is no significant difference between early
and late intervention for children with ASD, then that is what it should be reported on the
study findings.
The importance of finding more evidence regarding early intervention for children
with ASD will provide a pathway for parents and caregivers to enroll their children in
Applied Behavior Analysis Therapy regardless costs and complications. Cognitive and
social learning abilities will increase over time as early intervention increases. Therefore,
verbal and non-verbal communication will be developed to access especial needs.
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