Everyone is happier in the HAMOC: Exploring The “Holistic ABA Model Of Care”
Author: Raizy Schwartz
Affiliations: Regency ABA
Abstract
As the field of ABA evolves, the need for improvement in various aspects of ABA as a practice increases. This review aimed to determine if implementing the Holistic ABA Model Of Care (HAMOC), improves the outcomes of ABA in clinical settings, for individuals with autism of considerable cognitive strength. In designing HAMOC, the following questions were explored. What evidence is there currently to prove that the components of HAMOC – including ACT, self management, and Today’s ABA – adhere to the seven dimensions of ABA? How can skill based training, OBM, and providing resources for BCBAs improve their level of care? What is the importance of using these training methods to encourage BCBAs to engage in collaborative care and assessment? How can we ensure that the HAMOC significantly improves social validity and treatment outcome overall, in a trauma informed manner? Scholarly research articles were collected from peer reviewed sources to assist in the research process. Throughout this paper, it was established that the components of HAMOC are evidence based, and are shown to improve overall treatment outcome, while adhering to the seven dimensions of ABA. It was determined that agency settings should incorporate the components of HAMOC in order to promote a positive rapport between client and provider, and to increase long term client and staff satisfaction.
Keywords
Applied behavior analysis, social validity, mental health modalities, conceptual systematicity, acceptance and commitment therapy, self-management.
Introduction
Applied Behavior Analysis (ABA) is an evidence-based and widely accepted treatment for individuals with autism spectrum disorder (ASD). ABA, grounded in the principles of behavior analysis, employs evidence-based strategies to assess and modify socially significant behaviors. It also takes a highly tailored and individualized approach to treatment to meet the specific needs of each client. As the field evolves, the need for improvement in various aspects of ABA as a practice increases. For example, there is a need to incorporate considerations of private events into ABA, so that a complete treatment that addresses a wider variety of functions and behaviors can be better delivered. In addition, more emphasis can be put on the proper training of Board Certified Behavior Analysts (BCBAs) by making resources more readily available, performing routine ABA assessments, and encouraging the use of self-management skills in treatment, all while adhering to the seven dimensions of ABA as laid out by Baer, Wolf, and Risley (1968). Effective collaboration between interdisciplinary team members should be incorporated into BCBA’s training curriculum to maximize client outcomes (Brodhead, 2015). Lastly, there is a need for a more trauma-informed approach to the delivery of services, such as the groundbreaking work discussed in Greg Hanley’s “Today’s ABA” (Hanley, 2020).
Recent research supports the use and efficacy of Acceptance and Commitment Therapy (ACT) within ABA. The use of ACT in ABA is rooted in Relational Frame Theory, a facet of ABA that focuses on understanding language, cognition, and psychological flexibility. ACT is a promising therapeutic approach for behavior analysts working with neurodivergent individuals with advanced verbal repertoires, as it acknowledges the importance of the “inner world,” a term used to describe private events (Donahoe & Palmer, 1994). Much of the ABA treatment has focused on overt behaviors, but ACT allows for focus to be on private events – a component critical to radical behaviorism as defined by B. F. Skinner (1945). ACT has been addressed in various behavioral-analytic journals, providing evidence that it not only produces meaningful outcomes, but that it is also socially accepted while adhering to the dimensions of ABA (Bordieri, 2022; Tarbox, Szabo, & Aclan, 2022). When applied appropriately, ACT can be integrated into ABA to promote psychological and emotional well-being.
There are many advantages to using evidence-based strategies such as Behavioral Skills Training to train BCBAs, including decreased burnout, increased client satisfaction, and improved treatment outcomes (Clayton & Headley, 2019). Despite the ongoing research consistently reporting their benefits, these training strategies are often overlooked when training BCBAs. Providing BCBAs with a database of resources such as visual supports, antecedent stimuli, manipulatives, and concrete programs can also lead to improved outcomes. Multiple studies have proposed that collaboration between families, teachers, and clinicians throughout the treatment process is also necessary for positive outcomes for participants (Donaldson & Stahmer, 2014; Smith & Eikeseth, 2010). There is overwhelming evidence that interdisciplinary collaboration is crucial, and efforts should be made to ensure that BCBAs are trained to be prepared for such settings.
Each decision regarding ABA-based treatment should be heavily influenced by assessment results and empiricism, as that ensures that the treatment program aligns with each individual’s unique needs and learning trajectory. Therefore, it’s crucial to use ABA assessment tools to assess, and reassess, throughout the treatment process. (Cooper, 2019).
Koegel and colleagues (1992) had emphasized on the benefits of incorporating self management components to a treatment plan decades ago, and a growing amount of recent work has reiterated that importance (Marshall & Roher, 2022; McHugh, Zane, & Monroe-Gulick, 2023). Self determination can be strengthened through choice-making, and as clients develop their own treatment plan, they slowly build up their repertoire of skills needed to be the driver of their own life.
As the field continues to advance, BCBAs must continually reflect on the seven core dimensions of ABA, with an emphasis on remaining conceptually systematic (Baer, Wolf, & Risley, 1968). This ensures that all aspects of an intervention are backed by the evidenced-based principles of behavior analysis. As such, maintaining conceptual systematicity in applied behavior analysis is critical for ensuring optimal outcomes. Additionally, conceptual systematicity provides practitioners with an organized framework for interventions, allowing them to tailor treatments to individual needs while ensuring that research and science is behind them.
Despite their recognized effectiveness, ABA has been criticized for lack of client assent, making the treatment process more challenging and limiting its efficacy. The terms “assent” and “consent” are related concepts, but there are important differences between the two. Consent refers to the legal approval given by a competent individual to participate in a study or undergo a medical intervention. It is typically obtained from the parent or legal guardian of a child participant, and it is always gained in ABA settings. On the other hand, assent is an active affirmation from the child participant and is an opportunity for them to express their agreement or willingness to take part in the intervention. It is not a legally binding agreement like consent, but rather a way to involve children in the decision-making process and respect their autonomy. Clients are more likely to engage with intervention packages if they have control over their environment and choices in achieving desired outcomes (Odom et al., 2019; Hanley et al., 1997). Greg Hanley devoted his work to including assent in a newer way of practicing ABA, coined “Today’s ABA”. Today’s ABA involves the Practical Functional Assessment (PFA) and Skill-based Treatment (SBT) (Hanley, Iwata, & McCord, 2003; Hanley, 2020).
The proposed model of care, referred to as the Holistic ABA Model of Care (HAMOC), uses each of the components above as a framework for a complete and multifaceted model of care. HAMOC combines the foundational existing concepts with more recent evidence-based approaches to enhance the effectiveness and comprehensiveness of care. HAMOC focuses on the following elements. Firstly, it utilizes ACT to address deficits from within. Superior training packages for BCBAs are also implemented, giving them access to resources, and training them to effectively collaborate with team members. HAMOC stresses on constantly assessing and reassessing to ensure socially significant progress, and it incorporates self management techniques together with Greg Hanley’s Today’s ABA (Hanley, 2020), all while adhering to the dimensions of ABA.
Research Question:
This review aims to determine if implementing HAMOC serves as a comprehensive model of care that improves the outcomes of ABA in clinical settings, for individuals with autism of considerable cognitive strength. The proposed treatment package takes existing evidence-based ABA concepts, and combines them with more recent innovations, to provide a complete model of care that emphasizes a trauma-informed approach. In designing HAMOC, the following questions were explored. What evidence is there currently to prove that the components of HAMOC – including ACT, self management, and Today’s ABA – adhere to the seven dimensions of ABA? How can skill based training, OBM, and providing resources for BCBAs improve their level of care? What is the importance of using these training methods to encourage BCBAs to engage in collaborative care and assessment? Does the Holistic ABA Model Of Care significantly improve social validity and treatment outcome overall?
Overview of Applied Behavior Analysis
ABA is a scientific approach that applies the principles of behaviorism to improve socially significant behaviors through objective measurement, experimental analysis, and systematic interventions. Behavior analysts utilize reliable measurement to track progress and make data-driven decisions. (Cooper, 2019). Referring to the seven dimensions of ABA laid out by Baer, Wolf, and Risley (1968) – generality, effective, technological, applied, conceptually systematic, analytic, and behavioral – is essential to designing effective interventions that lead to desired outcomes. One of the key tenets of ABA is its emphasis on behavior being observable and therefore measurable (Irwin & Axe, 2019). The emphasis on observable and measurable behavior distinguishes ABA from other approaches and contributes to its effectiveness in producing behavior changes (Schwartz & Kelly, 2021).
Careful consideration must be given to ensure that interventions remain evidence-based and grounded in the principles of behavior analysis. By integrating various modalities under the umbrella of ABA, practitioners can provide comprehensive and tailored interventions to individuals with diverse needs (Padilla, Akers, & Kirkpatrick, 2020). This integration requires effective communication and interdisciplinary collaboration to promote a cohesive approach within an agency (Brodhead, 2015). Priorities and methods may vary among the various members of a care team which poses challenges in communication, mutual understanding, and the promotion of a cohesive interdisciplinary approach. Overcoming these challenges requires open dialogue, shared understanding of each discipline’s contributions, and a unified commitment to effective and ethical practice (Donaldson & Stahmer, 2014).
Acceptance and Commitment Therapy
Acceptance and Commitment Therapy (ACT), built upon the principles of contextual behavioral science, focuses on promoting psychological flexibility and enhancing overall well-being. It emphasizes the importance of accepting internal experiences while committing to valued actions. ACT aims to enhance psychological flexibility by utilizing six core processes: acceptance, defusion, self-as-context, contact with the present moment, values, and committed action (Hayes et al., 2006).
Acceptance refers to making space for difficult thoughts and feelings instead of pushing them away. Defusion refers to viewing one’s own thoughts as only thoughts, which are fleeting and ever-changing (Kelly & Kelly, 2022). Defusion promotes conceptualization of private events as another type of environmental stimuli as opposed to a fixed truth. This dismantles the level of control that thoughts have over behavior and encourages alternative responding (Tarbox, Szabo, & Aclan, 2022). Self-as-context refers to recognizing the separation of one’s being from other internal or external events, promoting the flexibility of perspective-taking (Levin et al, 2012). This component of ACT works similar to defusion, in that it encourages the individual to recognize that the source of private events is within the self and discourages them from assuming those events as an external objective truth (Hayes, Strosahl, & Wilson, 1999). Contact with the present moment is the importance of mindfulness, or being attentive to the present without fixating on past, future, or fictitious events (Tarbox, Szabo, & Aclan, 2022). The core process of value suggests one to know their personal priorities in life and to act according to those priorities, while focusing on the journey and less on specific goals (Hayes, Strosahl, & Wilson, 1999). These ideals all come together as a framework for committed action, which is the goal of engaging in value-directed behaviors.
ACT is distinguished by its contextual approach and reliance on relational frame theory (RFT). The contextual behavioral science approach underlying ACT considers behaviors a result of both the situational context, and internal verbal networks. This approach provides a framework for understanding the dynamic interplay between an individual’s experience and behavior (Hayes et al., 2006). The foundation of ACT lies in the fundamental principles of behavior analysis, such as reinforcement and behaviors maintained by function, but broadens the way that functions are conceptualized and the contingencies of reinforcement (Kelly & Kelly, 2022). Additionally, ACT also incorporates key processes from cognitive behavioral therapy (CBT), such as mindfulness and acceptance. When using ACT through a behavior analytic lens, it is important to integrate both approaches to create an environment that encourages self-acceptance while teaching observable behavioral skills.
The use of ACT is an exciting and fairly recent ideology explored by ABA researchers, although its theoretical foundation is based on the principles of behavior analysis (Enoch & Nicholson, 2020; Hayes, Strosahl, & Aclan, 1999). A growing number of studies have suggested the potential benefits of combining ACT/RFT principles within ABA. A study conducted by Pingo, Dixon, and Paliliunas (2020) provided support for the incorporation of ACT into behavior-analytic interventions, demonstrating improved work performance across five participants. Multiple behavior analytic studies with interventions that included various components of ACT have reported improved performance and socially significant outcomes (Brazeu et al., 2017; Szabo, 2019; Twohig, Shoenberger, & Hayes, 2007; Wang et al., 2020).
Implementing ACT as a contextual behavioral science approach requires a contextual understanding of behavior, considering the unique circumstances and factors influencing an individual’s actions. This allows for a more comprehensive and effective application of psychological principles. ACT has gained recognition for its flexibility, evident by its use in various different schools of thought and branches of ABA practice, such as Contextual Behavioral Science (Hulbert-Williams et al., 2016).
Relational Frame Theory (RFT) is a psychological framework that provides a comprehensive understanding of language, cognition, and behavior. RFT proposes that human language and cognition are derived from relational understanding, which involves perceiving and relating stimuli based on their contextual functions rather than their physical properties (Cooper, 2019). This theory has paved the way for numerous empirical studies and applications in various domains.
Key concepts of RFT include relational framing, derived relational responding, and arbitrarily applicable relational responding. Relational framing refers to the ability to relate stimuli based on their functional relationships, enabling the formation of complex cognitive processes and language (Blackledge, 2003). Arbitrary relational responding allows individuals to establish relations beyond direct experience and apply them to novel stimuli or situations (Cooper, 2019).
RFT has been applied in various diverse areas. It has been instrumental in research on rule-following, analogical reasoning, intelligence, theory of mind, and psychopathology (Hayes & Hayes, 1989; Hayes et al., 2001). The application of RFT in the field of psychopathology has provided valuable insights into the development and maintenance of various mental health conditions. Techniques derived from RFT, such as defusion, have gained prominence in the treatment of psychological distress and ACT (Blackledge, 2003). Defusion involves helping individuals distance themselves from unhelpful thoughts and emotions by altering their relationship with them (Tarbox, Szabo, & Aclan. 2020).
The use of ACT and RFT within the field of ABA has garnered increasing attention. As mentioned above, both methods offer complementary approaches that emphasize the role of language and cognition in human behavior. The fusion of ACT/RFT principles within ABA has led to the development of various techniques that address cognitive processes and promote psychological flexibility. For example, cognitive defusion as part of a behavioral package has been shown to reduce repetitive and restrictive behaviors in autistic children (Eilers & Hayes, 2015). This technique reduces the impact of cognitive fusion and allows individuals to have a better understanding of their own private events. Other techniques such as mindfulness-based interventions and values clarification exercises can be integrated into ABA interventions with positive outcomes and acceptance (Bordieri, 2022; Brazeau et al., 2017). Other research has shown the effectiveness of acceptance-based interventions in reducing psychological distress and promoting valued action in individuals with various psychological conditions (McEnteggart, 2018).
Collaborative Care
Collaboration between behavior analysts, teachers, and professionals from other disciplines can foster integrated practice and enhance the development of curriculum and interventions (Brodhead, 2015). Not only is it beneficial, but vital in ensuring ethical treatment. Focusing solely on behavioral interventions without considering other treatments can be harmful, especially if there is a medical concern (Cooper, 2019; Newhouse-Oisten et al., 2017). Collaborative care is also vital to treatment fidelity and minimizing behavioral contrast, ensuring that the improvements of treatment are present across a variety of settings (Kelly & Tincani, 2013). Working with other stakeholders can also help to identify both short and long-term goals as well as determining the feasibility of interventions across all domains (Sheridan & Kratochwill, 2007).
Assessment
Another important component of holistic care is recognizing the need for ongoing assessment and evaluation to ensure that the appropriate goals are being established and met. Constant assessment should confirm that assent to treatment has not changed (Bordieri, 2022). Assessments are also vital to the teaching of new skills and the pathway of intervention (Donaldson & Stahmer, 2021). Skill assessments need to be constantly performed to verify that an intervention is making meaningful changes. Skill assessments should also be administered to BCBAs to affirm competency and determine strengths and weaknesses. As a data-driven practice, it is essential that all components of treatment are assessed for social significance, effectiveness, and acceptability (Cooper, 2020).
Self Management
Despite the proven effectiveness of ABA in improving outcomes for individuals with developmental disabilities, there are concerns regarding its client-centeredness. There is a perception among some professionals that ABA is not client-centered, leading to a reluctance to incorporate ABA principles in their practice (Welch, Missiuna, & Polatajko, 2016). This reluctance leads to deeply client-centered techniques, such as self-management, to be overlooked.
Self-management strategies have emerged as an integral component of ABA. Self-management interventions empower individuals to independently monitor and regulate their own behavior, fostering self-control and promoting the generalization of skills across various settings. Through self-management techniques, individuals with autism gain increased independence and autonomy, contributing to enhanced social validity of the intervention (Copeland et al., 2021).
Numerous studies have shown that self-management can improve clinical outcomes and increase client empowerment and self-determination (Koegel et al., 1992; Lee, Simpson, & Shogren, 2007; Marshall & Roher, 2022; McHugh, Zane, & Monroe-Gulick, 2023). Self-management procedures can be incredibly useful in building independence in those with autism spectrum disorder (Marshall & Roher, 2022). In their 1997 study examining client preference for function-based treatment packages, Hanley and colleagues found that individuals were more likely to accept treatments when they personally identified with the reinforcement system used by the clinician or therapist. This highlights the importance of creating a collaborative relationship between client and provider for treatment plans to be effective and well-received. As ABA practitioners strive to provide high-quality care, the integration of self-management approaches is crucial in promoting client empowerment, self-determination, and improved overall well-being. Agency settings should incorporate self-management strategies for all individuals with ASD.
Greg Hanley’s Today’s ABA
Greg Hanley is one of the pioneers in ABA who raised awareness on trauma informed care. He implored fellow BCBAs to reconsider the “outdated” ABA approach, where the therapeutic relationship was not valued, and stressed the value of a trauma-informed approach (Hanley, 2020; Rajaraman et al., 2022). He coined his approach “Today’s ABA”, and he came up with both the Practical Functional Assessment (PFA) and Skill Based Treatment (SBT). He argues that client’s should be able to “vote with their feet,” and choose to be present. This would allow progress to occur in a humane fashion. He suggests a tiered approach, where you first surrender to the client fully, while giving them everything they love to bring problem behavior down to zero. He explains how the treatment would then continue by teaching the base skills of communication, toleration, relinquishing, and transitioning, during which the provider empowers the client by giving in to them at the slightest sign of distress. Once the client acquires the four base skills, additional skills are incorporated. He stresses on the televisibility characteristic of his approach, meaning that sessions using PFA and SBT would be well perceived on live TV, without needing any additional explanations for why certain things had to be done. (Hanley, 2021). Research shows that his approach produces quick and significant behavior change, in a humane and socially significant fashion (Coffey et al., 2020).
Seven dimensions of ABA
Baer, Wolf, and Risley (1968) presented the ABA world with seven dimensions of ABA: applied, behavioral, analytic, technological, conceptually systematic, generality, and effective. Applied means that goals are individually tailored to reflect what is important to the client and family. Behavioral is having the target behavior described in observable and measurable terms, allowing accurate data to be collected and progress to be monitored. Analytic refers to the established functional relationship between the intervention and the target behavior. Technological means drafting detailed procedures that are easily understandable and replicable, and conceptually systematic means adhering the principles of behavior analysis. Acceptance and Commitment Therapy (ACT) is conceptually systematic, for example, because it’s foundational reliance on RFT is based on the principles of ABA. Generality includes having skills maintain and generalize to various appropriate scenarios other than the teaching setting. Effective means establishing that there are significant, positive changes in behavior (Baer, Wolf, & Risley, 1967). All of the components in HAMOC can be practiced in a way that adheres to the seven dimensions of ABA, and doing so will ensure a positive and ethical therapy experience.
ABA-Based Training Strategies and Resources for BCBAs
Having well trained ABA professionals is an essential prerequisite to the above-mentioned components of HAMOC, and to socially-significant change in general (Cooper, 2019). As employers, ABA agencies have the opportunity to implement evidence-based training programs such as Behavior Skills Training (BST) to encourage professionalism and competency in BCBAs (Peterson, Philip, & Catagnus, 2022). The BCBA training curriculum fails behavior analysts in that education post-degree becomes much more limited. Since BCBAs are often responsible for supervising RBTs and prospective BCBAs, utilizing ABA based training methods will create a ripple effect, fostering continuous efficient training and competency.
Skill-based treatment (SBT) and Organizational Behavior Management (OBM) are sub-disciplines of ABA that aim to improve behaviors (Abernathy & Lattal, 2014; Coffey et al., 2021). SBT was developed rather recently by Hanley and colleagues (2014) and has been used to decrease dangerous problem behaviors in children with autism and increase appropriate behaviors. Since it’s important for organizations to keep their educators and practitioners fluent in the basic ABA principles, the use of OBM can be beneficial in improving performance, safety, and organization morale (Abernathy & Lattal, 2014). Successful training programs greatly increase the likelihood that the skills taught will be learned efficiently and effectively (Clayton & Headley, 2019). These programs can be designed to enhance BCBA’s knowledge and application of ABA techniques. Highly knowledgeable BCBAs are able to individualize treatment plans, facilitating growth and improvement. With OBM and SBT techniques, companies can identify areas of concern and work to improve the conditions of those areas in need of development. In addition, these training tools can be used to promote agency-specific values and specialties. Promoting positive organizational cultures that value innovation, continual learning, and collaboration can ultimately improve employee competency and therefore improve client outcomes (Abernathy & Lattal, 2014).
BCBAs spend a lot of time brainstorming and writing out programs and targets, establishing the appropriate succession of targets. They must also figure out ways to best teach learners the target goals chosen for them. Teaching of skills can be enhanced greatly by the use of manipulatives. Research shows that manipulatives can promote greater skill acquisition in participants (Morales, 2021; Peterson et al., 2008). BCBAs often use visual supports such as visual schedules, social narratives, and antecedent stimuli in their sessions. Behavior analysts would highly benefit from having an arsenal of manipulatives to choose from provided to them, cutting time spent preparing and ultimately improving outcomes.
Discussion
This review set out to determine if implementing HAMOC (Holistic ABA Model of Care) would improve the overall effectiveness of ABA in an agency setting for high-functioning individuals with autism. Throughout this paper, it was established that the components of HAMOC are evidence based, and are shown to improve overall treatment outcome, while adhering to the seven dimensions of ABA.
The paragraphs above prove that ACT is a conceptually systematic intervention that increases overall wellbeing through targeting psychological and emotional processes. Incorporating self-management in ABA improves social validity and treatment outcome (Copeland et al., 2021). When collaborative care is used, the client is more likely to have more positive outcomes (Sheridan & Kratochwill, 2007). Adhering to the seven dimensions of ABA ensures that HAMOC is implemented in accordance with ABA standards.
Implications for practice
Through the use of OBM and SBT, BCBAs can be trained to facilitate the best possible treatment outcome. BCBAs can be further supported by having access to readily available materials, as this would very likely decrease burnout rates, increase their time efficiency, and increase the use of manipulatives in session. Agencies can provide their BCBAs with memberships to online communities and forums that allow BCBAs to have access to a bank of programs and materials, to engage in discussions and share resources with peers. Alternatively, agencies can have their own organized archive of materials and programs, with a library for physical stimuli. These things can ultimately greatly impact treatment outcomes. In the future, agencies should incorporate the components of HAMOC in order to increase client and staff satisfaction.
Limitation of Study
This literature review did not analyze how treatment effects maintained after intervention faded, and generalization strategies also wasn’t discussed in this paper. These limitations should be considered.
Implication for Research
More research can be done on the topic of incorporating other mental health modalities into ABA, like Cognitive Behavior Therapy, for instance. In addition, research can be done on creating a unique assessment for those using the HAMOC.
Conclusion
The holistic model of care for ABA in an agency setting is a comprehensive approach to treating individuals with ASD. By utilizing a combination of evidence-based behavior techniques, personalized assessment, and individualized treatments tailored to meet individual needs, this model provides an effective means to support the growth and development of clients. This model also promotes a stronger connection between client and provider, for more successful outcomes in the long run. Through all the efforts discussed in this section, BCBAs are equipped to make a positive impact on the lives of individuals receiving ABA services.
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