APU Health & Fitness Intellectible Podcast

How Applied Behavior Analysis (ABA) Treatment Transforms Children with Autism

Podcast featuring Dr. Gary L. Deel, Ph.D, J.D.Faculty Director, School of Business and
Mary Strittman, Board Certified Behavior Analyst

Children with autism or other behavioral disorders can make incredible progress through intensive behavioral intervention services. In this episode, APU’s Dr. Gary Deel talks to Mary Strittman, a certified behavior analyst, about her work providing applied behavior analysis (ABA) therapy. Learn about this type of evidence-based therapy, how it’s used for children of all different abilities, and why it’s so important for everyone to know more about behavioral disorders to better understand the challenges and abilities of children.

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Dr. Gary Deel: Welcome to the podcast, Intellectible. I’m your host, Dr. Gary Deel. Today, we’re talking about applied behavior analysis therapy and support services for people with behavioral challenges. My guest today is Mary Strittman. Mary is a board certified behavior analyst with over 10 years of experience providing ABA therapy to children. She has experience working with individuals with autism spectrum disorder, ADHD, down syndrome, and epilepsy.

Mary’s primary areas of interest in clinical practice include teaching functional communication to children through a variety of modalities, independent living skills, and social skills. She is also passionate about providing ongoing supervision to individuals pursuing their own board certification. She completed her BACB course sequence through Florida Institute of Technology and her master’s degree in general psychology from Nova Southeastern University. Mary, welcome to Intellectible, and thank you for being our guest today.

Mary Strittman: Thanks for having me.

Dr. Gary Deel: Absolutely. So this is a broad subject. There’s a lot to talk about. And in full disclosure to our listening audience, it’s personal to me. I know it is to you as well. And we know each other as fellow members of the autism community. I have a son who is on the autism spectrum, and obviously you are a provider of services for people with autism, and so that’s how we know each other prior to this podcast.

And I want to talk a little bit about the work that you do without limiting quite yet to specifically to autism, because in your introduction, of course, I mentioned several different kinds of challenges that children may encounter in their development. If you could for our listeners, break down a little bit the differences between these different kinds of challenges or condition, what the symptoms are like for people that may not be familiar with them, and what kind of services you provide as a professional in the field of behavior analysis and modification?

Mary Strittman: Well, I’ll start with the latter part of that question. So ABA, applied behavior analysis, is the science of human behavior. And we seek to identify areas of social significance to help our clients, in my case, children, with different behavioral challenges to acquire the skills that they need to be successful in life.

And so in my introduction, you mentioned functional communication. Oftentimes, children on the autism spectrum or with other developmental disabilities might have difficulties communicating, whether that might be speech delays, or just lack of communication in general. Some of the students that I have worked with may not communicate in the typical modalities that we think of.

So, obviously, our goal is for individuals to be able to communicate through speech, because that is what is most widely accepted and understood by the general population. But I’ve also had the opportunity to work on using augmentative or alternative communication, AAC devices, with individuals with special needs. I’ve also used sign language, or the Picture Exchange Communication System, also known as PECS, with individuals to help build up that communication repertoire in whatever modality is best for them.

Additionally, you touched on functional living skills. Things that we do around the house every day, like going to the bathroom, brushing our teeth, bathing, getting dressed, all of those things we learned to do at a very young age, and that helps us be more independent as we get older. And so those are really important skills to teach to children on the autism spectrum and otherwise, even neuro-typical children. We want them to learn those skills so that they’re able to be more independent.

And then you also touched on social skills and our ability to communicate. I mean, this goes hand in hand with functional communication, but our ability to communicate and interact with others is really, really vital for us to be successful and independent in our lives.

For kids, that is the premise of all of their social interactions is being able to say, “Hey, let’s go ride our bikes at the end of the day or after school,” or “Hey, can you help me with this problem? I’m not really sure what this pertains to,” in, say, a math class. And our social skills are carried on throughout our lives. And we need to be able to interact with others. Just as you and I are having a conversation, or if I am going to a school, and I’m interacting with teachers for the betterment of the kids that I’m working with, I need to be able to interact with people in a variety of ways. Those are some of the most important skills that we end up working on in behavioral therapy to try and help our kids be more independent.

Dr. Gary Deel: Perfect. Now I’m glad that you explained what ABA therapy is, because I know that when I first was introduced to ABA therapy through my autistic son, I really had no clue what that looked like. So for someone that is not familiar with ABA therapy, or what an ABA therapist does, could you sort of break down in the simplest of terms what does that look like? If I was observing an ABA therapist working with a child who had behavioral challenges, what would I be seeing?

Mary Strittman: It looks different for everybody. It really does. Some of the younger learners that I work with, the two- and three-year-olds, it’s going to look like I’m playing with them and doing nothing else. But there is a very specific way that I might be presenting things, that I might be interacting with that child. And again, some of our goals include the ability to learn how to communicate. So if I’m on a playground with a child, and they really, really love to jump off of the top of the playset into my arms, they might say, “Hey, Mary, catch me.” And then I catch them. So again, it’s one of those situations where it looks like play, but really I’m very methodically working on reinforcing that child’s communication.

For others, I worked with an older child, and I actually don’t even want to refer to him as a child, because it was a young man who was about to graduate high school. And we actually sat down, and we worked on interview skills to be able to get his first job. And so that obviously is going to look quite different than the two or three-year-old that I’m on the playground with. But, yeah, it looks different for everybody, but it is very interactive, and again, methodical in the way that we are presenting things and working on things. It just looks different for everybody.

Dr. Gary Deel: Now, you mentioned some good examples with young children, and even what sounded like maybe an adolescent patient of yours, but is ABA therapy something that is limited in terms of its accessibility to children and adolescents, or is it something that is available to adults who may need assistance? And could they benefit from it equally?

Mary Strittman: Yes. So the long answer is everyone should be able to access behavior analysis therapy. The unfortunate reality is that oftentimes these services are only covered by insurance companies. It can be costly to pay out of pocket for services, and insurance companies typically restrict coverage of services to children.

In Florida, for example, where I practiced for six or seven years, when a child turns 21 years of age, again, depending on their insurance, they are no longer eligible to receive services. And so, yes, everyone could benefit from receiving services, but primarily, at least in my experience, and I do work with children up to the age of 21, primarily insurance will cover services for those under that age.

Dr. Gary Deel: Now, conceivably, if an individual were capable of holding their own job, such as, for example, the young man you described earlier, that has benefits, and they have their own insurance, then that could provide a means for them to obtain their own therapy. But if they reach a certain age, what we’re saying, essentially, is they could fall off of their parents’ insurance, and then no longer be covered.

Mary Strittman: Yeah.

Dr. Gary Deel: So when we talk about the conditions that we’ve described, we’ve talked about autism a little bit so far. I know that in your introduction I also mentioned ADHD, down syndrome, and epilepsy. These are conditions at least at present without medical cures, without a silver bullet to completely resolve the underlying condition and the symptoms. So with that being said, is ABA therapy sort of the gold standard treatment given that there aren’t any cures? Is this the most conventional means of addressing some of the challenges that come with these conditions?

Mary Strittman: ABA is considered an evidence-based practice. And I would refer to it as the gold standard, particularly for the treatment of autism spectrum disorders, but there is so much research showing its positive effects with those other populations that you listed.

Dr. Gary Deel: And in terms of the evidence for ABA, because the challenge, of course, from a scientific perspective is every child being different. It can sometimes be difficult to establish whether some particular treatment is working, because there’s an N equals one issue there. In other words, if you were fortunate enough, or unfortunate, I guess, depending on how you look at it, to have say 1,000 identical twins with exactly the same diagnosis of exactly the same condition and you expose 500 of them to ABA therapy, and the other 500 were a control group, then you can start to assess, but obviously with each child, you only have one of that individual uniquely. So how does the world of ABA, how do you attempt to sort of assess what’s working, what’s not, and how effective your efforts are?

Mary Strittman: That’s a really good question. In behavior analysis, we typically refer on single case experimental designs, as opposed to kind of what you described, having a 1,000 kids, 500 in an experimental group, 500 in a control group. We typically avoid those group designs simply because everyone is different.

So it’s difficult when you’re looking at a group design. It is challenging to determine the effects on an individual when you are looking at the whole. Using only one individual, and this is an overgeneralization, but for simplicity’s sake, if I look at one individual, say a five-year-old, I can collect data on their behavior, whatever behavior that might be. It could be their ability to independently ask for help. I could get kind of a baseline on what they’re responding looks like, how independently they’re able to do that.

And then that allows the child to kind of serve as their own control. So when I introduce certain prompting techniques, so I’m prompting them every single time to ask for help when I can see that they clearly need help with a challenging task. Then I can measure their effects or their responding compared to that baseline. So I can look at responding within the individual rather than a large group design. And in behavior analysis, we’ll replicate this across a variety of kids or a variety of behaviors, a variety of settings. There are a lot of different single-case experimental designs that we look at.

And when studies have been replicated over a certain number of participants, a certain number of research teams, we start to see some of the consistencies or inconsistencies in the data. And that’s what helps us establish those evidence-based practices within behavior analysis, when, like you said, N equals one.

Dr. Gary Deel: Right. Is it safe to say that, and obviously having such a wide variety of patients that you would see with a wide variety of conditions, but in your experience, more often than not does the practice of ABA therapy yield, I guess I’m tempted to say, “progress,” as opposed to, “success,” because success could vary in definition, depending on who you ask. But is it more common than not that you would see improvement in whatever it is you’re seeking to achieve?

Mary Strittman: So progress is typically seen for individuals receiving ABA services. Again, everyone is different. So their progress, it’s going to be at a different rate. Some of our younger learners, for example, I might see very, very quick progress. Their brains are like sponges, and they learn everything so, so quickly.

Whereas some of my older ones, that progress also can be seen, but it might be a little bit slower, because they have a longer learning history. They have a longer history of engaging in certain behaviors to obtain reinforcement. And then when you’re trying to introduce something new, something perhaps a little bit more functional that’s going to help them be more independent, there could be some resistance to that, but overall we typically see progress.

And if we’re not, we’re always collecting data. So we’re measuring that progress. And if we’re not seeing it, then we will make changes to the program. We will try to find other interventions that are a little bit more effective. And at the end of the day, if I’m not seeing progress with one of my learners, and we’ve exhausted all of our resources, then I may also look at referring them to other specialists that might be able to help them achieve whatever it is that they’re trying to achieve.

Dr. Gary Deel: Now, you mentioned something that I think is really important in that last answer, which was the difference across a sort of generality. Not to say that it’s always this way, but that in typical cases, as I understand it, the younger a child is perhaps the more receptive to behavioral modification or therapy they might be, just because they haven’t conditioned themselves into bad habits, or they’re more open to learning different types of skills and whatnot.

So I only wanted to emphasize that for the sake of making the point that if a parent is out there listening to this podcast, and they have a child who they suspect, maybe even sort of subliminally, may have a behavioral disorder, or maybe someone has mentioned it to them, and they’re resistant to the idea. They’re in denial, and as a parent of a child with a behavioral disability, I can understand that. But I guess my question is, sort of knowing the answer already, how important is it that they follow through, and not ignore it, or resist it, or live in that perpetual state of denial about a potential circumstance? How important is it that they jump on that early, and get the help that they need early on?

Mary Strittman: It is so important. And we have a very, very large research base showing the positive effects for young children who are receiving early intensive behavioral interventions. And this goes back to the 80s, where children would be receiving services for upwards of 40 hours per week. I mean, that’s a full-time job. For some of us, we don’t even work that much. And these children are receiving those intensive services, but the effects were very, very dramatic compared to those children who received fewer hours of services.

And the biggest change is when they reach kindergarten age. A lot of the children who received those very, very early intensive behavioral services, they were able to go into general education classrooms. They didn’t need to be in special education classrooms. They didn’t need that additional support.

For all intents and purposes, some of them were indistinguishable from their peers. And that’s not said from a viewpoint of attempting to erase their autism or anything like that, because that has been a concern that I’ve heard from a lot of people over the years is that, “Well, they have autism, and I don’t want them to not be autistic. It’s part of their personality.”

And I definitely, definitely respect that viewpoint, but for a child to be able to go into a classroom, and they’re not singled out as being different, I think that that’s really, really important, because that affects their social lives throughout their entire lives to have some sort of label that’s given to them from their peers. “Oh, they’re different.” Other peers might not want to interact with them, and that could really negatively impact them in the long-term. So for us to have studies that show all of these really, really positive effects by getting those early services, that is one of our evidence-based practices.

Dr. Gary Deel: Absolutely. And I think what you’re saying there, not to put words in your mouth, is not so much that we want to change the personalities or the identities of these children, but that we want to empower them with intellectual parity with their peer groups, so that they’re able to maintain their education in a K-12 system with their peer group, that they don’t fall behind, that they don’t suffer from social stigmas related to those differences. Differences in personality aside, we don’t want them to be admonished or disenfranchised by their peer group because they’re different in a way that is looked at as lesser by their peers.

Mary Strittman: Exactly.

Dr. Gary Deel: Do you see cases where parents commonly, you can identify a child that quite obviously has some behavioral challenges that probably ought to be addressed, but there’s a resistance from the parents to acknowledge that reality for fear of what comes next?

Mary Strittman: I have seen it before. Most of the time when a child is referred to our company for behavioral services, they have already gone and seen a pediatrician, who may screen them for signs of autism. And, again, I’m using autism as an example because that’s the population that I work with most often. And that is the population that most often has insurance coverage. There are a lot of restrictions when it comes to insurance coverage of behavior analytic services.

But that child will have been screened. They might have been referred to a developmental pediatrician, or a psychologist, or neurologist, and they may receive a diagnosis of autism. Sometimes parents will share whether or not they agree with the diagnosis, but once they have that referral in hand, they have the choice to call us, or they have the choice to not.

And, obviously, the ones that call us we’re very, very happy to help with whatever challenges they might be facing. And I hope through this podcast, and just working, and word of mouth as well, having parents who receive behavioral services for their child having good experiences, hopefully they will share that with others who might be experiencing some apprehension in pursuing behavioral services. And we’ll kind of get them on board with it, because it really does make a difference for so many people.

Dr. Gary Deel: And I think just speaking as a parent, if I can say the fear of the label is something that I can relate to. But I think the consequences of that label are far more benign than the consequences of ignoring that reality, and not getting the early intervention that, as you mentioned earlier, can be so crucial to normal, healthy development.

When you look at that variety of, because again, you talked about autism being the most common thing that you work with, and then you have ADHD, down syndrome, and epilepsy, is there any kind of trend line or scale that would suggest in your experience that any one of these particular conditions is more susceptible to modification through ABA than any others? Or is it really just individual based depending on the child that you’re working with, and the severity of the symptoms, and so on?

Mary Strittman: Yeah, I think it comes down to severity of symptoms, and the fact that everyone is different. I have worked with several individuals with epilepsy. I have an extended family member with epilepsy, and having that as a neurological disorder doesn’t mean that you can’t learn. I have worked with individuals who, again, they’re indistinguishable from their peers. That’s definitely not a make it or break it diagnosis, but I have worked with some who have had very, very severe seizure disorders. And there was regression every single time that they would have a grand mal seizure.

And as a result, you’re kind of always trying to play catch up because of that regression. So there’s definitely certain challenges, but overall most often I see progress. It depends on the individual, and the intensity with which they are receiving services, as well as the quality of the services.

Dr. Gary Deel: Perfect. We’ve been speaking with Mary Strittman about applied behavior analysis therapy and support services for people with behavioral challenges.

Mary, you had talked about some of those less common circumstances where if ABA is not effective or doesn’t see the desired progress, there might be other support services available just for the sake of elucidating for our listeners. I assume that would include things like maybe occupational therapy, speech pathology. Are there other things beyond the scope of those resources that even I wouldn’t be aware of that you might refer for those extreme cases?

Mary Strittman: I think speech therapy and occupational therapy are the referrals that I make most frequently. If there is a specific behavior that I’m seeing that may be better addressed by each of those therapies, also physical therapy. Oftentimes individuals who are receiving behavior analysis will also have referrals already for some of those services.

So speech therapy, within behavior analysis, we really, really like to work on verbal behavior and communication, as I touched on earlier, but there might be some speech impediments that we are not as good at focusing on, and sometimes might be better addressed by a speech therapist. Occupational therapists also may work on some writing skills or some fine motor skills that they’re specifically trained to address. And same for physical therapy, more related to gross motor skills, and strength, and movement.

There are also times where I have encouraged families to seek out other intensive services for something perhaps related to pediatric feeding disorder. So some of the children that I’ve worked with over the years are very picky eaters. It can lead to malnutrition, and there are programs out there that provide intensive feeding therapy for upwards of 30 hours a week. And sometimes we can work on feeding aversions, and we can work on some feeding therapy within behavior analysis, but the nice thing about having an intensive feeding program is that you have a team of people that are all trained to address those feeding disorders. And that can include a physician. That can include a behavior analyst looking at why they might be refusing food.

You can also have a speech or occupational therapist that’s specifically trained in looking at, “Well, do they have the oral motor skills to be able to swallow?” There’s a big team of people that are there to address the feeding aversion. And sometimes that really intensive therapy can be more beneficial than say an in-home program where we’re working with the parent to address this behavior. And that can be equally effective for some individuals, but at times where I’ve seen very severe malnutrition, I have referred to some of those more intensive programs.

Dr. Gary Deel: Now, for anyone listening who may be interested in a career in behavioral health, whether it be ABA or any of the others that we talked about. I talked a little bit about in your introduction your roadmap, is that fairly typical? In other words, to become an ABA therapist, is there a minimum education requirement and a licensure, or some type of credentials, or training?

Mary Strittman: Well, ABA therapist is kind of a generic term. And I think that that oftentimes covers board-certified behavior analysts like myself or a registered behavior technician, or RBT. And the truth of the matter is we have a variety of certification levels. And so I can briefly review those. Again, I’m a BCBA. I have a master’s degree, as well as additional coursework in behavior analysis.

I had to undergo an intensive supervision experience where I accrued 1,500 supervised hours with a board certified behavior analyst. And I had to sit for the BCBA test, which is a pretty tough test, but all BCBAs hold that credential. We also have BCBADs, who hold doctoral degrees. They’ve met those same requirements, they just have a different designation than BCBAs do.

At the bachelor’s level we have a board certified assistant behavior analyst. They have completed a bachelor’s degree and behavior analytic coursework, and their requirements are slightly less. They have to accrue a thousand hours of supervised experience, and they also have to pass a certification exam. For both of those credentials our requirements are actually changing at the beginning of January in 2022. And those supervised hours actually will be increasing. So it’ll be a more intensive program and experience for anyone who is pursuing board certification.

We also have a paraprofessional credential, and that is the registered behavior technician, or RBT, and these are really the frontline workers. They are the ones who are implementing the programs that are written by the BCBA, and they are receiving ongoing supervision by the BCBA. They typically have to have a minimum of a high school diploma, and they have to go through a 40-hour training pertaining to behavior analysis, and they have to receive ongoing supervision. The minimum requirement is 5% of the hours that they’re working they need to be with a board certified staff member.

Dr. Gary Deel: So to be an RBT, just to be clear, it’s not necessarily required that you have a college degree, although I would imagine that couldn’t hurt, but you need to have the 40-hour training, and you need to be supervised by a BCBA such as yourself?

Mary Strittman: Yes. You also have to pass a criminal background check and things like that. I mean, there are other requirements, but that’s the overview of it. And in my experience, the majority of RBTs that I work with have a bachelor’s degree. Our team in particular, we focus heavily on education. And so the majority of the RBTs that I work with, they already hold a bachelor’s degree. They’re pursuing their master’s degree in behavior analysis or a related field, and they’re looking at this as a long-term career goal. So just because the requirement might be a high school diploma, oftentimes our behavior technicians have more intensive training and education as well.

Dr. Gary Deel: And are the education and certification requirements that you identified, board certification or training, is that a national level requisite, or does that vary from state to state depending on where you work?

Mary Strittman: The Behavior Analyst Certification Board, or BACB, oversees our credentials, and currently the BACB is an international organization, and they will continue to be, technically speaking. Right now you can hold any of the BACB credentials, so RBT, BCABA, BCBA, anywhere in the world, but they will be changing some of those regulations in the coming years to only be, I believe the United States and Canada. And the reason for this is that different countries might have laws that might outline different regulations than what we have here in the US and Canada. And so other countries will be forming their own certification boards. So their credentials technically will be different, but right now, I mean, we have BCBAs all over the world.

Dr. Gary Deel: Perfect. So the last thing that I wanted to make sure we touch on in this hour is to address the question of what community members, and family members, and neighbors, classmates can do to be good participants in the process for children who are undergoing ABA therapy, because I think that there’s often mistaken or erroneous assumptions made. And look, kids are kids. They’re going to misinterpret situations because they’re kids, but even among adults, and I’ve witnessed this experience with my own son who has ABA therapy, that sometimes the parents of other children that are going to school with my son will misinterpret what having an ABA therapist means in the room.

And they might think that because my son has a therapist that he’s aggressive, or mean, or violent, or that he’s just unfriendly, and that he poses some type of threat to their own children. And I understand what it’s like to be a protective parent, but I want to try to demystify these bad assumptions and mistakes that parents make, and offer some advice on what they can do to be good participants in the process.

Mary Strittman: Absolutely. I think one of the biggest things that parents should remember, and people in general, is that behavior analysis is meant to be a helping profession. When you encounter an ABA therapist, a BCBA, an RBT anywhere, whether it’s in the grocery store, or it’s at the park, or it’s at your child’s school, remember that they’re there to help.

So there shouldn’t be an assumption that the child is engaging in really severe behaviors, that they are really aggressive, that they’re tantruming all day. It could be that that child just needs a little bit of academic support. They need help staying focused on things. If a child is engaging in some aggression, we’re there to try and help that child find other ways of communicating, and other behaviors to engage in besides that aggression, so that they can be more independent.

And I think it’s also really important to make sure that as a human being, whether you’re an adult, or you’re a kid, that we’re treating people with kindness. When we see a child who has special needs, or a child that has an ABA therapist with them, understand that you might only be seeing a very small snippet of their life. You don’t know the circumstances that are occurring necessarily during the full school day or at home, and their parents and their teachers are probably doing the very, very best that they can to help that child be as independent as possible, to help them with their social skills, to help them be academically successful. Just know that you’re only seeing a small portion of their day. And teach your kids how to be kind and befriend some of those kids.

I know a few years ago when my oldest nephew went to kindergarten or first grade, he made friends with a boy with autism, and it was just like second nature to him. And it made me so proud, because he didn’t push him away because he was different, or he might’ve engaged in certain behaviors that were different from his other peers. He befriended him, and having peer models like that, who are showing our kids with special needs how to be more independent, how to be successful in social interactions, those kids are really, really important. So teach your kids that kindness. Teach them to reach out and be a good friend.

Dr. Gary Deel: I think that’s awesome advice, and I think it’s perfectly accurate. Children aren’t born with stigmas, and they’re certainly not born with prejudices, but they’ll pick that up from any really role model that exhibits any kind of unnecessary hostility, or fear, or apprehension from something that’s different. So I think that’s really great advice.

Well, that’s all I had for today. The last thing I wanted to do is give you the opportunity to let our listeners know what you’re doing, and if they happen to have a need or an interest in this subject, how they can reach you. It’s my understanding, you have your own company for ABA therapy, and that your company operates in both Florida and Colorado. How can listeners, if they happen to live there, and they might have children, or maybe family members, or friends that they know who have children that could benefit from these services from your company, or if they want to reach you in general, what’s the best ways to try to get in touch with you?

Mary Strittman: Absolutely. So I work with Accelerate Behavioral Health. And as you touched on, we provide services in the central Florida and northern Colorado areas. The best way to reach us is to go to our website, which is acceleratebh.com. And through that website, you have our email address, our phone number, and you can reach out to our operations manager, Kasi Rubin, and she can tell you whether or not we are credentialed with your insurance in each of those states or in your area. And she can help you get the ball rolling on getting services started.

Dr. Gary Deel: That’s wonderful. Well, thank you so much, Mary, for sharing your expertise and perspectives on these topics with us. And thanks for joining me today for this episode of Intellectible.

Mary Strittman: Thank you so much.

Dr. Gary Deel: And thank you to our listeners for joining us. You can learn more about these topics by visiting the various American Public University blogs and podcasts. Be well and stay safe, everyone.

Dr. Gary Deel is a Faculty Director with the School of Business at American Military University. He holds a J.D. in Law and a Ph.D. in Hospitality/Business Management. Gary teaches human resources and employment law classes for American Military University, the University of Central Florida, Colorado State University and others.

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