Archive for the ‘Uncategorized’ Category

Part 3 – The Errors we See- Discrimination challenges in children with autism and Learning Disabilities

September 21, 2017 2 comments

The author is a Board Certified Behavior Analyst working with Behavior Momentum India. The views in this blog are his own. I hope to keep in mind parents and therapists as I write and will try to keep the jargon to a minimum. Do feel free to contact me via

In parts 1 and 2 of this series, we saw the various examples and types of errors children with autism and learning disabilities make.  In the concluding part of this series, we will see some proven strategies to overcoming error patterns while teaching receptive language.


Don’t be too sure that the child ‘knows’ – do a counterbalanced assessment with distractors

Firstly it is important not to be satisfied with a confident assertion that the child ‘knows’ and has acquired the targeted discrimination. The first is done by performing a thorough assessment with the target items and distractors counterbalanced across all positions and across the number of times asked for.

For example, if you are testing for discrimination between say a,b and c ( or tiger/ leopard/panther or cup/spoon/ fork for that matter) then a minimum of 18 trial probes will be needed.  a, b and c should appear in each of the three positions in the array equal number of times and the instruction asking the child to select a,b or c should be done an equal number of times for each one in each position. This will help us find out if there is a  position bias in the students responding, a dominant item response or other errors such as win-stay errors.  An example of a counterbalced array is as below for assessments.

Array Position of stimuli Ask For Observer 1 Observer 2
Left Mid Right SD
1 yellow PINK brown   brown
2 PINK yellow brown PINK
3 brown yellow PINK yellow
4 yellow brown PINK yellow
5 brown PINK yellow brown
6 PINK brown yellow yellow
7 brown yellow PINK PINK
8 PINK yellow brown yellow
9 yellow PINK brown yellow
10 yellow brown PINK PINK
11 PINK brown yellow PINK
12 brown yellow PINK brown
13 PINK yellow brown brown
14 brown PINK yellow yellow
15 yellow brown PINK brown
16 brown PINK yellow PINK
17 PINK brown yellow brown
18 yellow PINK brown PINK

I once had a heart-rending situation.  Mom was confident that ‘Of course, my child knows his mom’. With due permissions, I ran a test. when there were 3 ladies, one of them being mom standing at random distances from the child we asked the child to give some item to mom, he would go and give it to the nearest person. The results were not much better when they were equidistant or when we instructed the child to “go to mom”. While the child would engage in play and singing with rhymes and other manners of sharing affection with her, he could not respond based on the instruction, “give this to mom” or ” go and touch mom”

Don’t be too sure that the student ‘knows’ – Are there some inadvertent prompts :

To rule out the possibility of inadvertent prompts a parent or therapist may be giving, it is important to have other people conduct the same set of assessments. If the child succeeds with everyone with a scientific assessment then it is possible to conclude that the discrimination is acquired. If the child is not able to make correct selections at more than chance rate ( only 33% of the times correct when an array of 3 stimuli is used and child is asked to select one randomly) with other people then either there is a failure to generalize, or, more likely the discrimination acquired is faulty.

Re-cap: error patterns exist if:

■Selection is right sometimes – wrong sometimes “ inconsistent”

■Response starts before instruction is given ( the student is basing responses on some ‘rule’ other than listening to you and selecting’)

■Child attends to /looks at a particular stimulus before instruction is given ( Sometimes instructors instruction coincides with child’s pre-selection)

■Responding occurs  without scanning  ( but some do respond well without directly looking)

■Escape behaviors happen  during receptive ID tasks

The first step is to ensure correct level of  discrimination in target selection :It is not a good idea to train fine or nuanced discriminations if grosser discriminations are not in place – Example – subtle shades in colors, words such as meet/ meat , sew/ sue, concept of honest vs dishonest

discrimination applicators-2022599_1280


Some strategies to overcome error patterns in teaching receptive language/  discrimination tasks:

No one procedure is guaranteed to work. but if you give considerable thought to the various options you have and if you are prepared to be flexible and if you take data on correct responding and errors under different strategies you will soon find what would work. For a full tutorial read Grow and LeBlanc (2013) – they have put it all together in the form of a tutorial. You will still need a guidance from an experienced Behavior Analyst for children with severe discrimination problems

  • get an observing/ attending  to the stimuli   before  the student responds :
    • Prompt to attend to the therapist – ” look at me” / other attention getting tactics before issuing instruction
    • It can be a simple prompt to look at each of the stimuli
    • A prompt to attend to a critical feature – match stripes before asking to select zebra from an array of zebra, horse, and deer.
    • student echoes  the instruction to confirm that he has heard it right ( Instructor says “zebra”, student says “zebra” and then proceeds to select Zebra from an array of 3 animals
    • Non-vocal children can make a sign corresponding to the instruction and proceed to make a selection
    • In fine discrimination exercises, example ‘b’ vs. ‘d’ – answer first whether the semi-circle is to the right of the line or to the left
  • Minimize inadvertent prompts from parent or therapist such as
    • eye gaze prompts – look directly at learners face and avoid looking at stimuli while giving instructions
    • A relaxing of facial features when student hovers over the right selection
    • small movements of therapists hands or eye movements
    • patterns of instruction ( example always ‘cow’ first, ‘horse’ second and ‘zebra’ third; position-wise – Right, middle, left)
  • Introduce multiple targets simultaneously – over teaching one may make it difficult to introduce new targets
  • By rotation, cover each target equal number of times within a session
  • Introducing sequentially is not recommended as teaching in isolation, simple discrimination is not likely to help with acquiring subsequent discriminations ( Grow et al., 2011, Gutierrez et al., 2009)
  • Use at least an array of 3 unless you are targeting opposites- with 2, the student has a 50% chance of being right anyways !
  • Improve Behavior consequence – A strong reinforcer for correct response And a loss of privileges or delay to reward – guided by Fisher, Pawich, Dickes, Paden  & Toussaint (2014).
  • If there is a position or side bias – counteract with more trials with success in other positions or increase array size
  • If there is a long history of errors with certain targets consider starting with a new set of targets  altogether

If the responding demonstrates improved discrimination, you are on the right track. Otherwise be flexible, look at the rate of correct and error responses across sessions and with professional guidance attempt an alternate strategy.

Happy teaching discrimination.

Selected References


Fisher, W. W., Pawich, T. L., Dickes, N., Paden, A. R., & Toussaint, K. (2014). Increasing the saliency of behavior–       consequence relations for children with autism who exhibit persistent errors. Journal of applied behavior analysis47(4), 738-748.

Grow, L., & LeBlanc, L. (2013). Teaching Receptive Language Skills. Behavior analysis in practice6(1), 56-75


The Errors we See- Discrimination challenges in children with autism and Learning Disabilities – Part II

The author is a Board Certified Behavior Analyst working with Behavior Momentum India. The views in this blog are his own. I  hope to keep in mind parents and therapists as I write and will try to keep the jargon to a minimum. Do feel free to contact me via

In Part 1 of the series we saw the types of discrimination challenges and issues we run into when teaching children with autism or other learning disabilities.  These are often a part of larger error patterns that children acquire inadvertently because of the way materials are used, the way responses may be prompted or the way they are reinforced. In this second part, we will look at inspecting and understanding error patterns. In part III we will look at strategies to avoid and overcome them.

Most of the receptive language tasks involve :

  • the teacher presenting an array of 3 or more items, asking for one of them
  • prompting and fading prompts if the child does not know the correct response
  • and rewarding ( reinforcing)  correct responses and ignoring incorrect responses.

Several potential errors creep in depending on how the training procedures are run.  Step one, in most cases, we must recognize that the student may not really interested in acquiring the discrimination between purple and Red or Tall and short. We believe, these are useful and functional and set up the teaching environment while the student could only aim to get a reward with minimum effort. The reward can be a preferred item or activity given by the therapist for correct responses or just completing the task as fast as possible and getting away from it all ( Technically. these are called reinforcers that increase future occurrence of the behavior that they follow) !! Behavior Analysts, both researchers, and practitioners have, in studies since the 1960s documented the kind of errors that could happen and newer and newer strategies are still being researched for improving outcomes. Laura & Grow ( 2013), have published a great article which details the type of errors that occur in teaching receptive language and strategies to overcome them.

Most parents and therapists miss the first step- recognizing that there is a problem. After doing a few tests it is very easy to be deluded into believing that the child ‘knows’ what is being taught though he sometimes makes incorrect responses. Some of the error patterns and how they creep in are discussed below:

I bet on a position ( Dominant position bias):

When you place pictures or dolls of cat, dog, and cow in an array and ask for one, say ‘cow’,  the student could adopt several strategies to complete the task which does not require him/her to listen carefully and make a correct selection – One is a position bias. As a student, I go for one particular position more often,  for example, the right most. Soon the therapist/mom inadvertently starts placing the target item there more often in that position, for, after all, the therapist or mom is also rewarded by students correct responses. The mistakes that happen when the target item is in other positions are overlooked and attributed to the student being ‘inconsistent’. In such a strategy, the student can completely avoid paying attention to what the instructor/ therapist/parent is asking to be selected( Technically called the Auditory stimulus presented by an adult which should serve as a discriminative stimulus for the student response).

I bet on a particular target item ( Dominant Response Bias):

Using the same example, possibly because I was taught ‘cow’ first and reinforced several times, even when the new targets of dog and cow are introduced I keep selecting cow more often regardless of what I am asked to select. On the occasions when I am correct, I get rewarded. Sometimes, this too could result in the teacher/ therapist asking for ‘cow’ more often creating an illusion of successful discrimination!

I bet on a familiar looking item :

There was a student who could identify spoon, cup, pen, socks, fork, lunch box, toy, and nearly a dozen such items from an array of 5 different objects. He never made a mistake until his teacher started presenting the array with 2 or more from his ‘known’ list. Then he started making mistakes. In the earlier procedure, the student merely had a rule that is something like ” If I see that familiar one, I will go for it”.

I respond based on body language or other inadvertent cues from the teacher:

While teaching receptive language the teacher may be inadvertently supplying additional cues which indicate where the correct responses lie. The student can be sometimes seen intently looking at the teachers face before selecting the item asked for. Some inadvertent prompts could be

  • the therapist’s eyes  dart at the target item before she asks for it (called eye-prompts or eye-gaze prompts)
  • the target item could be placed closer to the child than the other items, as the student’s hand hovers over an incorrect response the therapist’s features are taut and they relax as he switches to the correct response midway
  • the teacher uses exaggerated intonation correlated to a specific target ( Biiiiiig vs small, nineteen versus nine) but does not fade such intonation prompts.

Switching bias :

The student, after being asked to select big, switches the next response to small ( even if ‘big’ is asked for again) because historically his therapist has always switched the target from the previous teaching trial.

Random responding:

Here the student randomly selects any item without regard to what was asked. Afterall,  in an array of 3, he could be successful 33% of the times and that is fine!

Stimulus Overselectivity:

Stimulus over-selectivity or attending to one part of an item to the exclusion of all other parts of the whole could result in errors. For example, a child who looks only at wheels may find discrimination between a car, a truck and a van difficult.

Generalization Problems:

While discrimination is acquired with specific items taught it has not generalized to novel items 0r contexts.

Laura and Grow in their 2013 article talk about several evidence based strategies to avoid errors and teach receptive identification to children with autism.   These include counterbalanced assessments and presentations, requiring an observing response, avoidance of instructor errors, use of simultaneous targeting versus introducing targets one by one and use of appropriate array sizes.  In addition, Fisher, Pawich, Dickes, Paden and Toussaint (2014) conducted a very important study that explains how and why it is important to manage the consequences of correct responses in relation to errors ( they call it managing the behavior-consequence salience for children with autism who present persistent errors).

We will discuss these strategies to over come error patterns in part II of this blog series.


Selected References

Grow, L., & LeBlanc, L. (2013). Teaching Receptive Language Skills: Recommendations for Instructors. Behavior Analysis in Practice6(1), 56–75.

Fisher, W. W., Pawich, T. L., Dickes, N., Paden, A. R. and Toussaint, K. (2014), Increasing the saliency of behavior-consequence relations for children with autism who exhibit persistent errors. Journal of Applied Behavior Analysis, 47: 738–748. doi:10.1002/jaba.172

The Errors we See- Discrimination challenges in children with autism and Learning Disabilities – Part I

July 22, 2017 1 comment

The author is a Board-Certified Behavior Analyst and works with Behavior Momentum India as a Research Associate, Faculty in teaching Applied Behavior Analysis course sequence and trains therapists who work with children with autism. He attempts to avoid jargon to make topics in Applied Behavior Analysis intelligible to parents of children with autism and learning disabilities, students, and therapists. The views in this blog are his own. This is the first blog and is expected to run into 3 parts because of the vast amount challenges in teaching receptive language to children with autism and recent advances.

David is a 4-year-old boy with developmental disabilities. One day his mom was excited. She was working at training identification of everyday objects from a small array of 3 different objects and he seemed to get it right with 7-8 objects such as a spoon, cup, top and fork wherever they are placed in an array. At the ABA center he went to during the day, his case manager was surprised by mom’s report. At the center, David would only get his identifications right only 25- 30% of the time, around a chance level of success, as if he were selecting randomly. He requisitioned videos of sessions from home and played them a few times over and found that a simplified array of stimuli was being used. There would be the target object, selecting which produced rewards and two other objects such as scissors and crayon that the parent never asked. David had figured that he needs to go for the spoon or the cup whenever they appeared in the array- he did not have to listen to what was asked for and make a discriminated selection. When probed with spoon, cup, and fork in the same array, hi correct selections dropped to chance levels as now the correct response depended on his selection also tallying with what the adult asked for.

Girls who buy nail polish need to know the difference between two shades that are close to each other in appearance- one could be “just her type” and another one not so! Children with autism and learning disabilities often have serious problems mastering discrimination tasks. One of the reasons is making a selection based on one element or feature of an object instead of attending to all the parts. This is called stimulus over selectivity. For instance, a child whose attention is only on wheels may not be able to identify a car if a truck and a van are also present in the array of vehicle pictures. Examples of making a response based on attending to an incorrect part abound. Discrimination training procedures involve the use of rewarding correct responses, prompting and prompt fading procedures and may inadvertently result in responses with errors or prompt dependence.

Let’s look at some more examples of errors. At a simple level, let us say a student is taught to respond to the instruction “touch head” by touching his or her own head. When “touch elbow” is introduced as a next target, the student could proceed to touch his head as soon as he hears the word “touch”. Similar problems exist with training to answer questions such as “what is your name” and  “What is your mother’s name”. The response “David” could be blurted out as soon as “what is” is heard. A child who is taught to answer “air” when asked what does fan give could reply with “air” when asked what does cow give”. It is quite possible that the “what” or “give” part of the question controls the students answer of “air” and not the “fan” or “cow”.

At a certain stage of learning, generalization must stop and discrimination must set in. There could also be a problem of over generalization without discrimination setting in (or being taught). A child taught to request for “hug” from parent’s could request hug from complete strangers. A child who is taught to say “daddy” with her dad’s picture (let’s say dad sports a beard in the picture) starts labeling other pictures of persons with a beard also as “daddy”. Many children on the spectrum who perform discriminative tasks with nouns well, fail when it comes to discriminating even between the basic colors of red, blue, green and yellow. I have come across students who do a perfect job of matching red card to card, blue card to blue card and so on. However, when they are asked to point at the red card or the yellow card or the blue, in an array that has all these cards things start going wrong. There is some other discrimination issue at work here. Discrimination challenges are part of everyday life with all humans. Husbands could buy the wrong gift on the anniversary day, a writer, could place too many, commas in his sentences, or cops could overlook important evidence at the crime site and obsess with non-essentials while the criminal is thriving and on the run. However, with children with autism and other learning disabilities, these problems acquire serious proportions across several areas of their learning and the error patterns could become stronger confounding parents and therapists.
Behavior Analysts use research based methods to identify error patterns, understand why they could occur in discrimination training and use specific strategies to overcome these.I will look forward to examining additional error patterns and the current state of research on how they can be overcome in the next parts of this series on discrimination training.

Your queries will help me reflect further. Do send them to

Autism – A brief historic perspective

November 21, 2016 Leave a comment

History is in the past but can help place things in perspective. While autism diagnosis strikes most parents from the blue, suddenly from no where, history says it has been around and recognized atleast 5-6 decades ago ( probably even earlier??). I will present some key milestones, the early blunders in understanding and current evolving understanding.

Retrospectively viewed, the earliest known description of symptoms of autism could possibly relate to Victor, a French feral child found in 1800 and believed to have lived alone in the woods for nearly the first 12 years of his life. Despite a young physician’s (Itard) intense efforts to teach him he only learned to speak two words but did make progress in his behavior towards other people. One day when the housekeeper was crying in grief over loss of her husband, Victor is reported to have engaged in consoling behavior and Itard reported this as progress. In 1867, Henry Maudlsey is said to have described insanity in children and his descriptions are consistent with today’s ASD.

Eugene Bleuler (1911/1950), a Swiss psychiatrist coined the term autismus to describe idiosyncratic, self-centred thinking during his work on schizophrenia.
In 1943, Leo Kanner introduced the modern concept of autism while describing 11 children with “autistic disturbances of affective contact”. He not only used it to describe children who lived in their own world cut off from normal social intercourse but also proceeded to distinguish it from schizophrenia indicating a failure of development instead of regression. Children with autism were described as inflexible, preferring sameness and rigid. In the following years, Kanner proceeded to hypothesize that autism was influenced by parenting, a dearth of maternal warmth { and this shoes how even scientists who are dead right about certain things can be equally dead wrong about certain things) and that many such children were not motivated to perform though not retarded.

In 1944, Hans Asperger used the term autistic psychopathy, now referred to as Asperger’s disorder in DSM- IV- TR and his study became widely known only in 1991 when it was translated in English by Frith.

The DSM I manual first released in 1952, classified autistic-like features under Childhood Schizophrenia. In 1967 Bruno Bettelheim popularized the theory of “refrigerator mothers” as cause of autism amongst public and medical community ( Another example of a scientist being dead wrong leading to harm in society) . These have since been disproved in research literature (Mundy etal., 1986). In 1977 the first study of twins helped change the perceptions and look towards genetics for understanding ethology of autism.

In 1987, psychologist Ivar Lovaas presented his first study demonstrating that intensive intervention can help children with autism learn. In the same year, autistic disorder replaced “infantile autism” in the diagnostic manual. Dustin Hoffman, essayed the role of a Autistic Savant in the movie “Rain man” which raised public awareness of the disorder while at the same time creating a mis-perception that all autistic individuals have savant like qualities. In 1993, Catherine Maurice’s book “Let Me Hear Your Voice: A Family’s Triumph Over Autism” brought into public view the effectiveness of use of interventions based on the science of Applied Behavior Analysis. In the same year, Jim Sinclair, an autistic adult started a neuro-diversity movement and spoke at the international conference on autism.

MMR vaccine was proposed as a cause of Autism in a Lancet study of 1998 but it was debunked and retracted though the controversy it raised continues till today.

In 2007, the US Center for Disease Control and Prevention estimated prevalence of Autism at 1 in 150 recognizing it as assuming epidemic proportions . this had climbed to 1 in 68 by 2014 ( “ Autism Spectrum Disorder: Data and Statistics” , 2014). As the prevalence figures kept climbing geometrically some researchers started questioning the validity of the prevalence figures. Gernsbacher, Dawson & Goldsmith (2005) have argued that the diagnostic criteria have been diluted, particularly between DSM III (1980) and DSM 4 (1990)  and other statistical errors contribute to a misperception of an epidemic.
In 2013 , DSM V was released and it clubbed several separate diagnosis into one diagnosis of Autism Spectrum Disorders.

Research into the cause of ASD continues to be unsuccessful in pin pointing the cause however there are advances in interventions  that can help individuals with autism acquire new skills and lead a better adapted life.

A history of Applied Behavior Analysis and evidence based interventions could be the next blog topic.




Autism Spectrum Disorder, (2014). Retrieved April 10th,2014 from

Autism: Rise of a disorder. Los Angeles Times 06 dec 2011, Data desk n. pag. Web. 10 Apr. 2014. .

Autism Timeline | Neurotypical | POV | PBS. (n.d.). Retrieved April 10, 2014, from http:/   /

Gernsbacher, M. A., Dawson, M., & Goldsmith, H. H. (2005). Three Reasons Not to Believe in an Autism Epidemic. Current Directions in Psychological Science, 14(2), 55–58.

Goldstein, S., Ozonoff, S., (2009), Historical perspective and overview. In S. Goldstein, J. A.   Naglieri & S. Ozonoff( Eds.,), Assessment of autism spectrum disorders (pp 1-13). New York, NY: Guilford Press

Wing, L., Potter, D.,  (2009), Historical perspective and overview. In S. Goldstein, J. A.   Naglieri & S. Ozonoff( Eds.,), The Epidemiology of Autism Spectrum Disorders: Is the prevalence rising?.  (pp 18-45). New York, NY: Guilford Press

Walsh, Neil, and Elisabeth Hurley. The Good and Bad Science of Autism. Autism West Midlands, UK. Web. 10 Apr 2014. <>.

Categories: Uncategorized

I know a family with a child affected by autism – I need to learn more to help

October 11, 2016 Leave a comment

On Autism and helping the children and families:autism_awareness_ribbon

Autism is a new challenge that humanity is facing. Children and adults with autism are seen to have problems in socialization,  communication and could engage in repetitive or stereotypic behaviors . Below are some examples of how autism manifests :

  • Very low or fleeting eye contact with others in environment, even when the child is being addressed 
  • Walks on toes
  • Is aloof, preferring to play with himself or herself, does not show interest in actions of others
  • Does not have appropriate peer relationships
  • Does not show empathy, may not look or offer help when someone else is in distress
  • Does not have appropriate play activities
  • Cannot communicate own needs or spontaneously comment on events around
  • Does not speak
  • Repetitive movements such as rocking, hand flapping
  • Repeatedly talking only about one or two favorite topics (dinosaurs, fire engines); limited interests
  • Non contextual speech, excessive giggling
  • Aggression causing injury to others or property destruction, Self-injurious behaviors

Autism should rank alongside epidemics such as Aids or Cancer in terms of both the devastation it causes on individual lives and families and in terms of scale.

In the United states the occurrence rate has accelerated to one in 88 children. Conservative estimates put the number of affected children at 2 Million in India.

So What could the rest of us do to help the family with a child with autism:

If you know a family who has a child with autism, apart from giving your time, moral support and showing sensitivity:

  • offer such parents hope that there are well researched and evidence based methods based on the science of Applied Behavior Analysis
  • inform them that with guidance from ABA professionals (see ) their child could learn new skills and become stronger and better adapted with consistent training

There is more information on the hope offered by Behavior Analytic interventions in




Article Review highlights – Evaluation of HBOT Therapy

Some of what I have written in this review is technical – If you are interested in highlights you could check the intro and conclusion section directly

Some excerpts  from my scientific article review
Using behavior analysis to examine the outcomes of unproven therapies: An examination of hyperbaric oxygen therapy

Lerman, D. C., Sansbury, T., Hovanetz, A., Wolever, E., Garcia, A., O’Brien, E., & Adedipe, H. (2008). Using behavior analysis to examine the outcomes of unproven therapies: An examination of hyperbaric oxygen therapy. Behavior Analysis in Practice, 1, 50–58.


Behavior Analysts are often confronted with a situation where parents of children with autism or other learning disabilities turn to other unproven, untested interventions ( also referred to as science fads, pseudo-scientific interventions etc.) in their search for improvement in their child’s rate of skill acquisition , reduction in inappropriate or challenging behaviors etc. Chelation therapy, vitamin doses, dietary restrictions etc. are some such examples. The BACB guidelines for responsible conduct enjoin Behavior analysts to study, appraise and review the likely effects of alternative treatments including those provided by other disciplines. The authors of this study have accordingly evaluated the effectiveness of Hyperbaric Oxygen Therapy – HBOT , a treatment that, while being expensive also has been gaining attention of parents of children with disabilities. Some parents have claimed that the therapy offers improvements in socialization, language, attending and compliance along with reductions in stereotypic behavior, aggression, disruption, self-injury etc. within 20 weeks. In keeping with the requirement not to turn a blind-eye but to scientifically and objectively evaluate alternate treatments or interventions, the authors have conducted this study.
The authors aim to validate their hypothesis that hyperbaric oxygen therapy does not offer any benefit beyond those offered by ongoing behavior analytic services and also lay down the procedures and challenges in conducting a behavior analytic intervention on unproven therapies.
A 7year old girl and two 6 year old boys with 8months, 3.5 years and 4.5 years history of receiving behavior interventions were chosen for the study ( as the study proposes to determine if the alternative intervention can provide more benefits than ongoing behavior interventions).
Further parents of these children had requested HBOT therapy.

The setting for ongoing behavioral services was a private clinic providing behavioral services in 1:1 format as well as in small group formats. The education covered academics, communication, peer interaction, self-care and play. The HBOT therapy sessions were provided in a chamber with 88% oxygen at 1.3 ata sold for in-house use. The chamber dimensions when fully inflated were 233 cm length x 11 cm width and 86 cm diameter.

Dependent variables – Behaviors measured:
Improvements with the therapy are claimed to be in language, task engagement, compliance, socialization, as well as decreases in inappropriate behaviors. The authors used very specific and measurable behaviors as dependent variables in the study. For example, in the area of communication, spontaneous communication, defined as signs or words emitted without prompts was measured (number of occurrences per session). Task engagement was measured as exhibiting targeted response within 5 seconds of instruction with gaze directed at task materials or therapist. Problem behaviors such as hitting, throwing materials were measured in terms of responses per minute as the authors state that each such response had a discrete beginning and ending.

The intervention involved 40-60 minute HBOT sessions administered in the chamber described above upto a maximum of 40 dives per participant. Considerations in setting limits involved providing claimed minimum threshold exposures and minimizing exposure to the unproven therapy. Acclimatization procedures were used initially followed by 60 min sessions with the chamber activated to provide oxygen in specified concentration and with the child present with access to favorite toys, books etc. throughout. If for any reason the child did not get a full 60 minute exposure, the session was excluded from the study. A therapist recorded data for each dive in terms of start time, end time, pressurization start, time when full pressurization was reached and total time at full pressurization. These could be noted from the gauges in the equipment. While the authors describe the HBOT therapy implementation in detail, they have not done an independent evaluation of the accuracy of treatment procedure implementation (treatment integrity).

To study the effect on outcomes therapists videotaped 10 minute sessions  and recorded  data on spontaneous communication, task engagement and inappropriate behaviors. Handheld computers, or desktop pcs and instant data software were used for scoring the above from video tapes.
Further baseline (pre-treatment) sessions data has also been recorded for control purposes.

Two of the children showed increasing trends in task engagement in the baseline phases capturing the effect of ongoing behavioral interventions on the dependent variables. HBOT therapy did not change the level, trend or variability. For the third child while the levels of task engagement were variable throughout the baseline phase, the gradual increase continued during and after HBOT therapy again suggesting that HBOT therapy by itself did not contribute to any additional beneficial effects. A confound was identified as increase in prompt levels coinciding with withdrawal of HBOT therapy and this was addressed by rescoring to ascertain the level of increase in prompts and its effect on increased task engagement.
Similarly, for problem behaviors, with two of the children decrease in levels in baseline phase continued during intervention. A slight increase in problem with third child was observed.
Discussions and Conclusions
One firm conclusion that authors reach is that the additional cost of HBOT therapy does not result in concomitant increase in benefits. While discussing limitations, they refer to limited generality as the study involved only 3 participants, the need to evaluate the effects of more intense HBOT treatments with possibly higher concentrations, some non-controlled confounds such as a reduction in instruction time along with increased access to preferred activities during HBOT sessions etc.


Lerman, D. C., Sansbury, T., Hovanetz, A., Wolever, E., Garcia, A., O’Brien, E., & Adedipe, H. (2008). Using behavior analysis to examine the outcomes of unproven therapies: An examination of hyperbaric oxygen therapy. Behavior Analysis in Practice, 1, 50–58.

Inspect before you respect – Is your Behavior Analyst competent and do they follow their ethical guidelines

October 18, 2014 Leave a comment

This note is written specifically for parents of children who receive interventions based on Applied Behavior Analysis (ABA).A special thanks to my colleagues in the field, Dr. Geetika Agarwal, Ms. Gita Srikanth, Ms. Sheela Rajaram and  Ms. Tasneem Hegde for reviewing the draft and for their valuable feedback. I hope I have been able to do justice to their inputs.

First off : ABA is not a therapy! Rather,  it is science based on which a number of  evidence based interventions have been developed to address socially significant behaviors across the entire human spectrum regardless of age, abilities or challenge.

Would you consent to have yourself treated by a person who has learnt medicine by working in a pharmacy? You should ensure that the person has studied medicine formally, keeps up to date with research in his field and conducts himself according to certain ethical guidelines. Unquestioningly and blindly trusting “experts” and “specialists” is not the way to go and this applies especially to people with whom you trust your children with learning challenges or problem behaviors.

So, when you have decided to give your child the benefit of interventions based on the science of Applied Behavior Analyst (ABA), one of the first considerations is to find out if the therapist who is going to work with your child is guided and supervised closely by a BCBA- D /  BCBA or a BCaBA .  The first two are Board Certified  Behavior Analysts ( Former is Doctoral) and the third is a Assistant Behavior Analyst who in turn needs to be supervised by a BCBA or a BCBA-D. The final responsibility, thus  for your childs programming goals , intervention procedures  and supervision of therapists should be with a BCBA-D or a BCBA.  Once you know the name of the professional, even if they are renowned and famous, see if they are listed in the BACB registry – –> find certificants.

For those in a hurry, let me present some  key questions  to ask  :

1. Is my child in good hands – is a credentialled Behavior Analyst designing and supervising the interventions ?

2. Are the interventions designed to ensure my child/ care giver does not come to harm – are  any risks/ risk mitigation discussed well with me and signed off?

3. Does the Behavior Analyst talk to me in plain english shorn of jargon.  Is he/she able to explain choice of teaching strategies/ interventions to my satisfaction?

4. Does the Behavior Analyst talk to me with data and graphed trends to communicate progress of my child?

5. Does the Behavior analyst respect and  maintain confidentiality  ?

6.  Is the Behavior Analyst a ” good citizen” ? For instance, is he/she  on the right side of the law in his or her dealings?

7. Is the Behavior Analyst on a continuous learning mode – does he/ she attend scientific conferences, present technical papers, disseminate knowledge

For those who would like to dwell a little deeper I’ll aim to elaborate on the above. A Behavior Analyst signs up to high standards of ethical conduct – I will list some of them that have a direct bearing for your child and yourself. You’d need to keep following and watching your behavior analysts behavior and convince yourself that he  or she displays behavior in consonance with these.

1. Do no harm , right to most effective treatment and least intrusive interventions : The primary client for the Behavior Analyst (BA) is the child or the vulnerable person receiving services. Parents / Guardians/ carers /teachers/ relatives  ( called significant others) will be secondary clients.  It is the BA’s responsibility to ensure that risks of any potential harm due to interventions are carefully analyzed, discussed with the client or significant others with risk management plans in place. Interventions covering these should be signed off in writing  with significant others to avoid any misunderstanding.

This also means, for example that in the event of your relocation or transition of services, the Behavior Analyst makes appropriate referrals and communicates status assessments to future provider to ensure the child does not suffer. Similar considerations should be seen if for some personal reason the BA is not able to continue providing services – they need to ensure presentation of suitable referrals where possible, a reasonable notice period , exit reports etc. Any information they share with third parties should be with your written consent.

2. Should maintain high standards of integrity in their personal lives and are seen as upstanding citizens . Even if they are clinically brilliant, they need to be operating on the right side of law. If you have any reasons to suspect this, stay away and consider reporting to the Behavior Analyst Certification Board ( ).

2. Keeps up with scientific knowledge : Does the BA attend conferences/ seminars on behavior analysis, is seen making efforts to use the lastest technological advances in the field?

3. Talks to you in plain english : Behavior analysts have an obligation to explain their intervention, assessments etc. in plain English for clients, consumers and professionals from outside the field.  If there is heavy jargon in their talk thats not intelligible to you , watch out! You could be dealing with style provider than substance.

4. Recommends the most effective evidence based interventions : There are a number of effective evidence based procedures such as Antecedent intervention,Joint attention intervention,Precision teaching, modeling, peer training package, schedules, self management etc.  that are based on Applied Behavior Analysis.   The BA, while discussing interventions for your child, should be able to substantiate their choice referring to scientific evidence base (e.g. number of scientific studies published in peer reviewed journals). If you are proposing a non- behavioral intervention, they could use scientific behavioral methods to evaluate its effectiveness.

5. Assesses, measures and communicates with data : Rather than say that they have been very successful, the BA should be able to discuss progress with data and  graphs of progress pre and post intervention. Do you see the BA constantly assessing progress and making changes on the basis of data ?

6. Takes informed consent :  Knowledge derived from interventions  with your child could be useful in  helping others facing similar challenges and add to the scientific knowledge base. In certain contexts the BA will take your permission in writing with a clause that such permission may be withdrawn by you at a later date.   The typical contexts include consent for use of videos data from interventions with your child in scientific conferences/ training programs/ website,  for including your child as a participant in a scientific study ( even if it benefits your child )  which may be published in a scientific journal and for taking up an intervention that involves reduction in socially inappropriate behavior .  It is  important for you to give the informed consent without any feeling of ‘pressure’  such as a fear that your child’s intervention may be compromised if you withold consent.

7. Confidentiality : The ethical Behavior Analyst will share information about your child only with personnel directly involved in designing and providing interventions .  Information Specifically identifying children are  masked ( unless significant others have consented otherwise) when information needs to be shared with peers or the larger community of Behavior Analysts such as in journal articles, technical paper presentations etc.

8. BA’s responsibility to the field of Behavior Analysis : You may ask, how does this concern me as a parent or recipient of services for my child . However, if the BA is seen disseminating knowledge about the field in various fora, seen fighting mis-representation of the field by non-qualified personnel , is seen attending, presenting posters and papers in national and international conferences you are probably seeing a ethical Behavior Analyst.

9. No Dual relationships or conflicts of interest please :  Behavior Analysts relationships with their clients and their significant others is strictly professional in nature and guided by a written contract. Behavior Analysts becoming best friends, joining you in family holidays, accepting gifts etc., would be in violation of their code of conduct as services to the client could be compromised.

These are but a few important points and some yardsticks lay people can evaluate the Behavior Analyst on.  It may be uncomfortable to do such an evaluation as  blind faith is a lot easier. However, with your child’s interests at stake I’d recommend nothing less than a diligent and ongoing evaluation.

Beofre I close, I must say that there are a number of changes you may have to undergo to make the most of your Behavior Analysts services – yes, it is a two way street.  Behavior Analysts prefer to address matters with data and trends and will need your buy in for the interventions with reasonable modifications . They may nor promise or guarantee miracle results but are likely to share information on interventions that have an evidence base and promise on going monitoring with data to demonstrate improvements. They are more likely to concerned with an improvement from here on rather than on an impractical standard thats out there. A Behavior Analyst may not entertain long discussions involving emotional reasons or hypothetical constructs ( invisible reasons that purport to explain the cause of problem but actually do not – see an early blog of mine on mentalism and circular reasoning) but will in a scientific way be able to draw your attention to the real function of problem behavior ( what does the behavior get as a consequence that makes it relevant) and the socially acceptable interventions that should work. This approach would aim to build trust based on objective evaluation of your child’s progress rather than ‘faith’ and this could be a subject matter for another blog!


%d bloggers like this: