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Decoding behavior

Finding the formula for change

There are two patients Dr. Mike Mozzoni will always remember: a stroke victim and the survivor of a cataclysmic automobile accident. Both had emerged from their life-shattering events with a traumatic dominant-side brain injury. Unable to dress themselves, or to handle many of the tasks that are critical to self-care and daily living, they faced lives of around-the-clock dependency.

Traditionally, this might not have been seen as a job for a psychologist. A physical therapist? Yes. An occupational therapist? Definitely. While psychology would have played a crucial role in helping the patients deal with the emotional aftermath of their circumstances, the challenge of relearning skills might more typically have been left to the purview of other rehabilitation therapists.

Dr. Mozzoni, a psychologist with degrees from Harvard and Florida State, used applied behavior analysis techniques to reteach the functional motor skills known in the profession as the Big Six Plus Six—reach, point, touch, grasp, place, release and twist, pull, push, tap, squeeze, shake. The results, which he published, were significant: both patients progressed from a total inability to dress themselves to being able to perform all the dominant and nondominant-side functions needed to button, zip, and pull themselves into their clothing.

“ABA has found its niche in areas that cannot be effectively addressed by other areas of psychology,” Dr. Mozzoni, regional program director for the Learning Services Neurobehavioral Institute in Colorado, says.

“You can’t talk somebody out of autism or a developmental disability. It takes a very different approach to address an individual’s problems.”

The therapy he provides involves breaking down complex activities into small, discrete tasks and helping patients master each task individually, guiding brain injury survivors through the process of relearning skills lost to accident or illness.

“It’s a matter of focusing on one task at a time so they can experience success with each one, and then putting them all back together so they function in an everyday environment,” Dr. Mozzoni says.

Applied behavior analysis, or ABA, is a rapidly growing discipline that uses a natural science approach to bring about socially significant changes in an individual’s life and in the world at large. The field’s strength lies in the systematic collection and analysis of data to validate incremental improvements in observable behavior.

Known best, and  practiced most, as a treatment for individuals diagnosed with autism, ABA has found a home in fields as disparate as the brain injury rehabilitation that Dr. Mozzoni practices, sport psychology, organizational management, regular and special education, gerontology, health and fitness, gambling addiction, crime and delinquency, sex therapy, neuroscience, animal behavior, and more.

“It’s an area with endless applications,” Dr. Joe Layng, senior scientist and co-founder of Headsprout, a Seattle-based company that has used ABA techniques to make dramatic improvements in the fundamental academic skills of some 300,000 children, says.

“It can and should be used in any aspect of life that involves human interaction. Any time that behavior is important and change is valued, ABA is the way to go.”

Changing lives

Sue, a developmentally disabled woman who has spent her life in an institution, is another client who has benefited from behavior analysis therapy. At 35, she spent her days engaged in self-injurious behavior and appeared most comfortable when she was physically restrained.

Dr. David Pyles, who serves as chief of behavior analysis for the Illinois Division of Developmental Disabilities, used an ABA technique called fading (gradually removing a desired stimulus) to bring about the behavioral changes he sought. He replaced constraints with wrist weights, which he only allowed Sue to wear when she was not inflicting injury on herself.

“It took a while, but she eventually learned that when she just cooled her jets she could enjoy wearing the weights, which evidently provided a stimulus that she liked,” Dr. Pyles says.

He then began reducing the size of the weights and eventually replaced them with a sweat band, which in turn gave way to a bracelet. He describes it as a classic ABA scenario that ended Sue’s self-injuring and her need for restraints.

Although behavior analysis has roots deeply entrenched in psychology (psychologist B.F. Skinner developed the set of principles that frame behaviorism), ABA differentiates itself from the social science base of its mother discipline. ABA practitioners agree that the precision with which they collect and analyze data that documents behavioral changes makes the field more analogous to the “hard” sciences such as biology, physics, or chemistry.

A common criticism of the field involves the perception that behavior analysts don’t share their clinical psychology colleagues’ interest in what a client feels.

“We get a bad rap for ignoring emotions and feelings,” Dr. Rachel Tarbox, associate professor of Applied Behavior Analysis at The Chicago School,” says. “We don’t ignore them, though. We treat feelings and emotions as behaviors.”

Behavior analysts, she explains, take the perspective that prevailing environmental conditions need to be analyzed with respect to their effects on human behavior.

“By manipulating these behavior-environment contingencies, we can bring about robust behavioral changes, which in turn, lead to individuals living happier and more productive lives,” Dr. Tarbox says.

As lead ABA faculty at The Chicago School’s Los Angeles Campus, Dr. Tarbox finds that many of her students have entered the field with a goal of working with children with autism. It is as a therapy for this disorder that applied behavior analysis has received the most attention.

“ABA techniques, when provided consistently and intensively as early intervention, can—and do—virtually eliminate the diagnosis of autism in young children,” she says. “As dramatic as that sounds, for those of us who do this every day, it’s just an accepted fact. To question it as an overstatement would be like questioning whether penicillin really cures ear infections.”

One distinction that separates behavior analysis from traditional psychology is what Dr. Chuck Merbitz, chair of The Chicago School’s Applied Behavior Analysis program, describes in terms of the inductive versus deductive model of determining treatment plans.

“Even though I value the opportunity to work closely with colleagues in other areas of psychology, I sometimes feel that we’re more like engineers than social scientists,” Dr. Merbitz says. “Psychologists typically use a hypothetical, deductive model of statistical analysis to decide a course of treatment. Behavior analysts use an inductive model; we pile up facts about a certain person and evolve individualized procedures based on those facts.”

Dr. Tarbox agrees: “We stay away from statistical analyses because what is statistically significant may not be socially significant.” She offers the example of an individual suffering from depression who experiences a 10 percent decrease in symptoms while on a certain medication.

“That result can be considered statistically significant. But the patient is still depressed 85 percent of the time so the results aren’t socially significant. As a behavior analyst, I would want to make changes in the patient’s environment to try to address the source of her feelings.”

A 75-year-old discipline

Tracing its roots back to the 1930s and Skinner’s work with operant conditioning, ABA developed from the experimental psychologist’s fascination with the intersection of environment and behavior. All human actions, he came to believe, occur in the presence of environmental stimuli and can be altered by varying those stimuli.

The concept of behavior analysis—or radical behaviorism, as Skinner termed it—represented a departure from prevailing psychological theory, which attributed actions instead to internal factors such as emotions and feelings.

Fast forward to the 21st century, when 135 universities—including 28 outside the United States—have approved course sequences to prepare behavior analysts, and a national organization oversees the certification of the approximately 6,000 board-certified behavior analysts (BCBAs) and associate behavior analysts (BCABAs). It is a rapidly growing profession that doubled its number of certificants from 2,838 in 2003 to 5,948 in 2008.

Although the field’s growth can be attributed largely to increasing demand for skilled professionals, Dr. Gerald Shook, chief executive officer of the Behavior Analyst Certification Board (BACB) admits that there is not a way to accurately quantify the need.

“There is no doubt that we need more BCBAs, but exactly how many is a hard question to answer—except to say that there are more people interested in the profession, more people getting certified, and more schools introducing programs to train them,” Dr. Shook says. “And every single graduate gets a job.”

One area of shortage is in the specialty that Dr. Mozzoni practices. Every year, 99,000 Americans receive a traumatic brain injury (TBI) that results in lasting disability; this includes combat veterans (the Veterans Administration estimates that TBI affects 22 percent of military personnel who have been wounded in action) and survivors of motor vehicle accidents, strokes, heart attacks, and near drowning.

“There are only between 50 and 100 of us who have been trained specifically to work with brain injury in this country,” Dr. Mozzoni says. “Although more and more people are going into ABA every year, the majority are going in to work with autism—that’s the area that is getting the most public attention.”

One indicator that ABA is receiving increasing recognition as an effective treatment for some areas of disability is changing health insurance laws.

“A number of states are now requiring that treatment by a BCBA—particularly for autism and other developmental disabilities—be included among services eligible for insurance coverage,” Dr. Shook says.

He cites TRICARE, the health plan that covers military families, which now pays for ABA services for children with autism, as long as providers are BACB certified.

One field, many applications

One does not need to be institutionalized or disabled to benefit from behavior analysis, which is now used throughout the world. (BACB data shows that the organization certifies professionals in 28 countries and on five continents.) It is used by Fortune 500 companies to improve the workplace environment, and by organizations of all kinds to solve management problems. Its use in sports, health, and fitness, which dates back at least to the 1970s, has helped improve golf swings, fine-tune ballet movements, see thousands through popular weight-loss regimens, and serve as the springboard for workplace wellness programs.

“It’s more of a blended area than other ABA applications are,” says Dr. Amanda Adams, who teaches in California State University-Fresno’s behavior analysis program and is active in the Health, Sport and Fitness Special Interest Group of the Association for Behavior Analysis International (ABAI).

“It’s incorporated into many areas, but the people who practice it most often do it as a hobby—maybe coaching a child’s soccer team.”

She adds that no university programs offer a specialization in this application of ABA.

“When you see the techniques used in gyms and wellness programs, they’re usually not overseen by someone who has been trained specifically in ABA. A workplace wellness program is probably run by a registered dietitian—it would be great if you could find someone who was both a dietitian and a BCBA, but that doesn’t happen very often,” says Dr. Adams, who, as a certified yoga and kick-boxing instructor, has used her skills to increase compliance in exercise routines.

Despite the proliferation of ABA applications, it is a science that struggles with misconceptions and, occasionally, controversy. The fallacy that behavior analysts cite most frequently is the belief that it is a treatment that is grounded in negative—and sometimes harmful—punishment techniques. There are those, they claim, who equate ABA with electric shock therapy and similar painful, or humiliating, responses.

“There are people who criticize us for being overly harsh,” Dr. Adams says. “While there were early researchers who incorporated mild punishers into their research, we use a much softer approach now—with children, it’s always play based. It incorporates the  natural environment and is based on positive reinforcement.”

Dr. Tarbox puts it more simply.

“ABA is all about getting the good stuff and avoiding the bad stuff,” she says.

The bottom line, behavior analysts agree, is that ABA works. Its focus on collecting and analyzing precise measurements at every juncture ensures that if a change in environmental stimulus is not working, it can be changed immediately.

“We often can tell within three days if a procedure is working,” Dr. Merbitz says. “The last thing we want to do is prolong an ineffective treatment. When our data tells us that we’re not achieving the results we want, we make changes and continue to record our data points. Our decision making is based, at every step along the way, on the behavior we observe in the person we’re treating.”

There seems to be little doubt that ABA will continue to grow as an area of expertise. As the need increases—and the alarming ascent in autism diagnoses is just one factor contributing to this trend—there will be an escalating demand for BCBAs. Concurrently, behavior analysts are finding new potential for the application of their skills in every corner of life.

“The sky’s the limit,” Dr. Pyles says. “The world is a big place for us. We can’t fix everything with ABA, but we won’t stop trying.”

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