Using ABA and the Verbal Behavior Approach to Treat Autism

Hi there and welcome back to another episode of the Turn Autism Around podcast. I’m your host, Dr Mary Barbera, and I am thrilled that you’re here today. Today we’re going to talk all about ABA or applied behavioral analysis, and the shift to the verbal behavior approach. If you haven’t listened to the first four episodes, I encourage you to do that before or after you listen to this one. It doesn’t matter, but you, if you have listened to anything, I would love it if you would subscribe, share the podcast and if you love it, leave me a rating and review to help me spread the word and get my message out to more parents and professionals.

Many people get confused about ABA programs and why there has been a shift from traditional Lovaas style ABA programs to a verbal behavior approach, and if it’s necessary to be adding BF Skinner’s analysis of verbal behavior into ABA, Or if that’s just an option. So, in this episode I’m going to cover the overall shift including the shift I made and how I moved from a Lovaas approach to a verbal behavior approach, how and why I wrote my book and started my online courses, and why I believe that adding the verbal behavior approach is absolutely essential.

This podcast is going to be a solo show where I’m going to be doing all the talking, and it’s going to be a little bit of a history lesson too. For those of you that have read my book, the Verbal Behavior Approach, which was published in 2007, it’s available in over 10 languages now and in that book in Chapter One, I do give the history of VB because I think it’s- It is confusing. You know, I talked in the first four episodes, I probably mentioned Dr Lovaas, his name and his classic study, if not every episode, most of the first four episodes. And in the first few episodes I also talked about my fall into the autism world and how learning about Lovaas’ classic study and the chances of a child becoming indistinguishable or recovering from autism. I talked about that. Learning about that just blew my mind and opened my mind to the possibility at that my son did have autism.

And so, no one probably would have really known about that study unless Catherine Maurice, who had a PHD and was mother of two children with autism, wrote her books, Let Me Hear Your Voice in 1993 and Behavioral Intervention for Children with Autism and Developmental Disorders, I think in 1996. And she documented her use of the Lovaas ABA approach. She told us in layman’s terms about Lovaas study, which took 59 children in California in the 1980s and for the experimental group, gave them 40 hours of one on one time of applied behavior analysis; a very set protocol that he developed. And in two or three years these children became indistinguishable from their peers; nine of the 19 or 47 percent. They went onto study them later at the age of 13 and these kids have made their gains.

So, from the time of the classic study, which was 1987 and Catherine Maurice’s books in the 1990s. So, in 1999 when Lucas was diagnosed, everyone who was doing quote unquote ABA was using a Lovaas approach. Or, even at that time, there was a lot of knockoff Lovaas approaches with without really knowing the Lovaas approach. So, some of the ABA approaches were not as strict as the Lovaas protocol. So Lovaas went on to form replication sites around the country and we were fortunate when we looked into ABA to get a consultant from the Lovaas replication site in Pittsburgh to travel to our home to start Lucas’s ABA program, and to come monthly for the first probably six months to make sure we were doing all the programs according to their protocol. Make sure we were, we were adding programs and holding programs based on their protocol and based on Lucas’s progress.

I remember it was my first consultant from the Lovaas replication site that told me that she really recommended that I get a babysitter for Spencer, my second son, and that I go down in the basement and I become a therapist, and I do ABA therapy with him three to five hours a week. And then before she would come every month, I was basically the lead, the lead therapist, if you will, and I would gather all the data and I would send her all the data, and then she would come and she would watch all the therapists in the chair and table with Lucas and make sure we were doing everything according to the protocol.

So, what that taught me was while it taught me about his program, I mean there was no, I’m upstairs, I have no idea what they’re doing. I also had a master’s degree in nursing administration and I found this very reinforcing to work, to learn how to work with my son, to learn how to teach him skills, and to gather the data for the consultant and to gather the stuff after she left for all her recommendations. So probably had that not happened, I wouldn’t have had this extreme interest in learning more and eventually becoming a behavior analyst myself.

So, as you can imagine, back in the late 90s and early 2000s with the push for 40-hour week programs, it was extremely expensive and no one wanted to pay for it. So, it involved a lot of due process cases. I went to due process, as I said in episode number one for payment for the Lovaas replication site consultant and the Lovaas protocol was number one, it was very strict. I mean they, they had replication sites. They were being very scientific about it. It tended to, the protocols tended to be like the…

I remember the first program that Lucas did was, was like, um, come here program. So, she would just say, come here, He would go there. He would have to do one task and then she’d say go play, so it involved a lot of receptive following directions. Come here and then once you got him to come here and put things in a box, then it might move up at some point to touching body parts, so touching nose versus touching belly. There was also a lot of imitation, so I remember the early days of the Lovaas approach; even though Lucas had a handful or two handfuls of words, there was no teaching me or teaching him how to use his words.

It was… the big goal was to get compliance and to teach him the skills that we could easily prompt. Like you can’t tell a child to say hi and prompt that in any way; but you can tell a child to wave hi and you can physically prompt the wave. So, I think that’s why the Lovaas therapy is like it is. It’s very much trying to gain compliance on the skills we can prompt.

Another thing besides the Lovaas protocol being very strict, it was very secretive. There was no, this is what’s coming next, or these are his skills and deficits. I remember the consultant bringing Lucas down into our basement by herself once a month when she was here and doing screening to see how he was doing. I think in hindsight they were probably looking for like a KOA control at that point without teaching a KOA control and they were probably doing screening to see if they could predict if he was going to be in the best outcome group, which he wasn’t. He didn’t. He made gains with the Lovaas approach for sure. But he wasn’t flying through. He wasn’t making tons of gains.

So right away I went to conferences from the first week he was diagnosed. I was just like, I have to find out how to help him. I would go to any conference, any camp, it didn’t matter. I was looking into what else, what else, what can I do to turn up the burners to give him what he needs? Um, and my first hearing about the verbal behavior approach-… and people called it different things, like nobody really called it the verbal behavior approach necessarily until I wrote my book. But the, the first I heard about verbal behavior was when my friend flew down to Florida to hear Dr Vincent Carbone at a workshop on verbal behavior. And when she came back, she basically was all enthused and she gave me the low down on the basics and basically told us, told me, that we should shift over to the verbal behavior approach.

So, what she told me and what I’ve learned over time is that, you know, the classic study that was published on ABA was in the 1980s and it was published- the study was in 1987. Parallel research was going on, I didn’t know about it, but at Western Michigan under the direction of Dr Jack Michael and a PhD student, Dr Mark Sundberg- well, he wasn’t a doctor then, so his PhD student was Mark Sundberg. And in the seventies and eighties, Dr Michael was doing a ton of work on trying to incorporate BF Skinner’s book called Verbal Behavior, which was published in 1957. Dr Michael was taking BF Skinner’s work, which really had nothing to do with autism, autism is not mentioned, it’s just an analysis of language and he was taking that book and trying to help kids with developmental disorders. So, there was a lot of work going on in the verbal behavior world that was important.

And Dr Mark Sundberg’s dissertation doctoral dissertation was published in 1980 and the title was Developing a Verbal Behavior Repertoire Using Sign Language, and Skinner’s analysis of verbal behavior. Um, so that was 1980, nearly two decades later in 1998, Dr. Mark Sundberg and Dr James Partington, who also I believe did his doctoral dissertation at Western Michigan, they wrote The ABLLS and the bigger book, which was Teaching Language to Children with Autism or Other Developmental Disabilities.

It was actually a book collection; it was this teaching language book, which was big; it was the ABLLS, which was a curriculum and assessment and a skill tracking form with a bunch of boxes; and a third book on how to write IEP goals based on that assessment. The biggest thing about this three-book collection, which I didn’t know about until late 1999 or even 2000, was that it was available to parents and Dr Vincent Carbone used the assessment, got these incredible videos, and started going around the country and the world to speak about using verbal behavior to teach kids with autism. And this was perfect for gung-ho parents to get their hands on something that they could learn how to help their own children.

I remember the very first time I saw Dr Carbone speak in New Jersey. I had to drive a few hours away, but it was a free lecture and I had heard all about it from my friend and I was doing the ABLLS on Lucas and we switched, um, actually when my friend got back from Florida and told us that we should switch, what happened was my consultant, my really great consultant from the replication site at Lovaas institute, she moved south, so I was going to have to be getting a new consultant anyway. And so, I looked into getting a verbal behavior consultant, which wasn’t a behavior analyst at the time. I mean the behavior analysis board was just forming and um, but Rutgers University under the direction of Mary Jane Weiss was offering some verbal behavior type consulting to home programs, and that’s when we switched there.

So, I had already switched consultants, but back then in 2000, 2001, it was like the wild west in terms of, you know, trying to program using The ABLLS because it was brand new. People really didn’t know how to program for kids using a verbal behavior assessment as much as a strict Lovaas approach, which was very lockstep.

But I remember the first time I saw Carbone, I drove to New Jersey. I got there super early because I didn’t know where I was going and it was probably before navigation systems, which I’m completely reliant on. Anyway. So, I go in an hour and a half early to this lecture and I see Dr Carbone, but he’s setting up DVDs and his speakers and everything. I literally thought he was the AV guy and I even asked him, I’m like, are you the AV guy? He’s like, no, I’m Vince Carbone. And I’m like, Oh my God, I’m so embarrassed.

But, um, it was an incredible lecture, you know, showing videos of little kids making great progress. Kids that were previously screaming… even in Catherine Maurice’s book, Let Me Hear Your Voice, her daughter took the Lovaas approach very easily and came to the table right away and everything. But her son, who was subsequently diagnosed and started a Lovaas approach, she says in her book that he screamed for six weeks. Like, thankfully Lucas didn’t scream even for 20 minutes. I think he screamed for 20 minutes when he, when the consultant first came and said, come here and he didn’t want to come. But, um, you know, that’s a lot of crying and distress.

And so, you know, when I saw Carbone’s videos of showing kids that were previously screaming with a more traditional ABA approach that we’re now running to the table to learn language and now talking a lot more, I was really impressed. So, as I said, I got the ABLLS, I got a VB consultant and I, I said in, I think it was episode one that at the end of due process when I testified for five hours for Lucas and in the year 2000, my lawyer told me that I should become a behavior analyst, which I started looking into.

And at the same time because I founded, I was the founding president of the Autism Society of Berks County, I also became an advocate statewide for ABA. And this is where I met other parent advocates. And what was happening was all these kids that were getting Lovaas type ABA treatment 40 hours a week, one on one in their homes, were now transitioning to kindergarten and first grade. And there was a huge disconnect between, like what we were doing at home versus what was gonna happen at school.

And I remember it was right around this time I was becoming, I was studying to become a behavior analyst. I was in this statewide parent advocacy group. I had the psychologists come to my home to look at Lucas’s home program a full year before he was going to transition. And I remember her looking like a deer in headlights like, oh my God. And she literally said, there is no way we can replicate any of this in a school setting.

So, flash forward, he’s ready to start kindergarten, I am pushing The ABLLS and verbal behavior type programming and a behavior analyst or someone who’s at least a behavior specialist at that point, to go into the schools for Lucas, and I was approached about working for the Pennsylvania Verbal Behavior Project, which was the grant developed and advocated for by a parent support group. And it first started out in 2002 with two classrooms up in northeast Pennsylvania. But when they were expanding in 2003, um, I received an email, you’re being considered for a position. I was ready to sit for my PCBA boards, but I wasn’t quite a behavior analyst at that point. So, I took the position and at that point there were 12 classrooms being supported through the state grant.

Through the Verbal Behavior Project, which I was the lead behavior analysts for in 2003 to 2010, we did three things. These were public school autism classrooms. We provided some trainings with Dr. Mark Sundberg and Dr Vince Carbone, and also trainings with people like me who are behavior analysts or studying to be a behavior analyst. I did some training, some materials like language builder cards and direct instruction curriculum, like language for learning and direct instruction reading and those sorts of things.

But the biggest part of our budget was always onsite guided practice. So a behavior analyst or those studying to be behavior analyst would go in and we would work with the teachers, the paraprofessionals, the speech pathologist, the occupational therapists we would work with, we would train the bus drivers, the cafeteria aids, anybody that wanted to be trained and wanting to be helped and we would bring in parents for some consulting, um, if they were having problems at home.

And so that was my entrance into the world of real verbal behavior with more than just my son, Lucas. So, Lucas was always a vocal learner. He is pretty easy going, had very few problem behaviors, uh, you know, initially. So, in the Verbal Behavior Project, I was all of a sudden working with literally hundreds of kids ranging from completely non-vocal. I had to learn how to teach sign, what that looked like, how to prompt. I worked with kids that were three to 21. I worked with teachers who were, ran the gamut from brand new. I have no idea what I’m doing to other teachers who began pursuing behavior analysts, the credentials themselves. We had about a third of our consultants, a couple years into it, a third of our consultants were autism moms turned PCBA, so that was a big push to that parent and professional collaboration was always front and center.

So, it was just a great, unbelievable experience. We did pre and post outcome data on all the kids. We initially used The ABLLS, the, uh, assessment of basic language and learning skills that my friend had taught me about. And then around 2006, Mark Sundberg started creating the verbal behavior milestones assessment and program placement. I may be getting that wrong, but it’s the BB map and he created that. Like I said, it was published in 2008. We started field testing it as part of the project in 2006. Um, so another thing that happened while I was working with the Verbal Behavior Project, um, the Verbal Behavior Project, I did leave in 2010. It’s still going on though. It’s, it’s now named the Pattan, P A T T A N, the patent autism ABA supports initiative. They changed the name for a variety of reasons, but while I was there, it was always the Verbal Behavior Project.

So, when I started working for the Verbal Behavior Project, I, like I said, I had hundreds of kids that I was working with. I was still also very much advocating for, to help pediatricians learn the early warning signs of autism, which I go over in episode two and three at length about the importance of that early detection. So, I was getting trained in the ADOS, which is the autism diagnostic observation schedule. And I also was getting training and getting certified in doing the Stat by Wendy Stone. The Stat is the screening tool for autism in toddlers.

So, I flew down to Nashville to get trained on the Stat and then when I flew back, I had to do some videotapes of me assessing a child, a young child, two-year-old with autism or signs of autism and also a typically developing child. So just by chance, this mom who as a nurse, um, she brought over her son David, who was two and showing signs of autism. She was on a wait list and I did the stat screening and he totally failed every subtest and you know, so he, he met the criteria for autism. Of course, I can’t diagnose autism, so I did the stat. I was able to also give her some advice about how to go about teaching some early imitation skills, how to go about teaching early manding skills, talked to her, but she was just so gung-ho and she’s like, you have to tell me more, what books can I read, what, where can I go? I need more training.

So, at that point I realized, like I said, well, you know, I read, Let Me Hear Your Voice. But that is, I don’t do things that way. I don’t let kids scream for six weeks. I, you know, I put manding first and you know, there’s a lot that I do differently. I mean, it was a great book for me. It gave me my start. So, I realized that I kept naming books but with big hesitations and I realized that everything I knew was basically in my head and I told David’s mom, I’m like, you know what, we’re having a two-day training at Pattan, why don’t you come, it’s next week. Even though, you know, if you were a parent of a school aged child who was in a Verbal Behavior Project classroom, you can go, no problem. I can get your seat, you know, just tell them that you’re very interested. She got to see. She was there for two days learning and I lost touch with her, but I had mailed in those videotapes of David to get my stat certification.

And four months later the stat personnel contacted me and told me that I had to redo David’s because I had happy birthday on the balloon and the balloon needed to be plain. And I was just like shaking my head like, you cannot even make this stuff up. So, I called David’s mom back and first of all I said, well, how’s David doing? And she said, oh my God, he is doing so well. In four months, I mean, right after I, she said right after I went to that two-day workshop, I learned so much. I came home and within two days he was talking, I learned how to teach him to talk and um, David came back over four months later, I redid the stat and instead of failing every sub test now he passed half the subtests and he was-, he didn’t meet the criteria for autism, although he did still go and get a diagnosis of autism or PDD NOS.

And I saw him years later and he was doing really well. So, I, at that point I knew I have to write a book. Um, so I don’t know if you know this, but over 90 percent of all books never sell more than a thousand copies. So much to my surprise and delight, the Verbal Behavior Approach has sold more than 50,000 copies and is available in over 10 languages. And it’s, it’s gotten, you know, it’s still selling as well as ever more than a decade later. I somehow managed to get Dr Mark Sundberg to write the foreword. And he also wrote on the back of the book, blurb for the back of the book that said, uh, this is the best book for parents of children with autism since Catherine Maurice’s, Let Me Hear Your Voice. That’s what he said.

And I like totally screamed when I got this blurb because Catherine Maurice had been- that had been my bible. Um, and so I was just really grateful to him and to everyone who has purchased the book. And in my book, I talk about The ABBLS because that’s what we were using back then, and that’s what was commercially available. Dr Sandberg was having us field test the VB map, but I don’t even think he had a real set title on it yet. And so, I wasn’t able to put anything about the VB map in the book. But, but in general, I do think that there is a lot of great advantages to the BB, to the using the BB map.

And in my online courses, my online courses are definitely built around the BB map because The ABBLS is all these check boxes of the good skills we want requesting or demanding and labeling and tacting and introvert; where the bb map is, the pro social behaviors are the good behaviors we want like manding and tacting and imitation and play and social, but we also have the barriers assessment, which is all the problem behaviors that get in the way and not just like problem behaviors like flopping on the ground, but also prompt dependency and obsessiveness and all the issues that really do get in the way of teaching these kids.

So, so there’s the milestones assessment as part of the VB map and the barriers and there’s also the transition assessment which really gets into self-care skills and group responding. And so, the BB map is, is definitely my assessment of choice for kids who are not conversational. Either they’re not talking at all, um, you know, have short phrase talking or even, um, you know, just aren’t fully conversational. If you are fully conversational, then the VB map assessment would be too low of an assessment and you would need a different kind of assessment, but I think the majority of the kids are either newly diagnosed or go on and continue with moderate to severe autism even if they are older, um, can benefit from an analysis and an assessment using the BB map.

So that’s kind of the history of why I shifted. Now I do want to say that we owe a huge degree of gratitude to Dr Lovaas. Without his work, you know, who knows where we would be right now and we have so much. The addition of the verbal behavior approach is not a different approach; it’s an addition and extension of Dr Lovaas’ research and it was kind of a parallel almost predated if we think about Dr Michael and his graduate students doing the work in the verbal behavior world in the 1970s. This didn’t, just verbal behavior approach didn’t just happen in the last few years. I mean, this has been extensively studied as a parallel but very complimentary and very much of an extension of Lovaas’ work and I think I had the great advantage of working with both methodologies with the Lovaas, strict replication site, ABA and then moving to a verbal behavior ABA approach.

In the beginning it was rough going, going from something that systematize that together, that formalized to kind of winging it and now I think with my book and the work of the Verbal Behavior Project and the extensive research in the analysis of verbal behavior journal and other journals extending all the research, I think we’re in a much better place to be providing more systematized, more systematized a delivery. But there are, there are critics of the verbal behavior approach. There are, and there are reasons you know, we don’t have small or large group-controlled studies like the studies. So, some critics are saying parents stay away from verbal behavior approach. It’s not proven there’s, you know, just stick with the traditional approach. But I, I have seen pre and post outcome data now. While it might not be published in a very scientific way as group outcomes, I mean with the Verbal Behavior Project, we have done thousands of pre and post outcome data on kids within my online courses. I have hundreds of examples of pre and post outcome.

My child wasn’t talking… 60 days later after taking your course, he is talking. Now I can’t write that up as research. I personally don’t have time to do controlled research. I am really on a mission to get the word out to help people and if I would’ve waited to add Skinner’s analysis of verbal behavior all this time, it would have been a little crazy because Lucas made gains other kids made gains, I don’t think it ever hurts.

It was interesting. I was at a cocktail party and years ago, but after I wrote my book, I was at a cocktail party. It was part of an ABA presentation and it was a poster session, last cocktail party and I met this man and he was from Philadelphia and he was working at a well-known institution and I was working for the Verbal Behavior Project, recently wrote my book and he said to me, Oh, well, if you have, you know, three year old, we do early intervention if you have three year olds down near Philadelphia, you know, feel free to recommend them to come to us.

And I said, okay, do you use the verbal behavior approach? Um, or maybe. I said, do you Skinner’s analysis of verbal behavior? I’m not really sure. And he said, no, no, we use strict discrete trial, Lovaas approach, it’s kinda the same thing. So, I’m like, okay. And I’m thinking like there’s no way I’m going to recommend anybody come to you. Like I am like Mrs. Verbal Behavior for goodness sake, you know. And he said, well yeah, I guess he could tell by the look on my face, how kind of like there’s no way I’m sending anyone your way.

So, he said, well don’t you think just some kids are discrete trial kids and some kids are verbal behavior type kid? And I’m like, no, I don’t agree with that at all. I think every child can benefit from using an analysis of verbal behavior. And so that’s what I think, I know we don’t, we don’t have the group studies, but if I waited for two decades and never did anything to increase Lucas’s manding intro verbals, like all this stuff, all this analysis to help him get better at language and to help all the children that I’ve worked with over the years to get better. You know, I think that’s silly. We’re not in competition. This is an extension. It makes ABA better.

You know, one funny question I get when it’s not really funny, but a common question I used to get more is which is better: ABA or verbal behavior? And that’s like saying which is better? Soda or sprite? Or which is better, religion or Catholicism? You see religion or soda are the umbrella terms and then underneath it are the types of Soda.

So, I consider the verbal behavior approach as a type of ABA but a really necessary part of ABA. Just like you would add the precision teaching ABA procedure, you know, we use, I use precision teaching all the time too, so it doesn’t have to be a competition. We just want to make sure our ABA procedures are as good as possible, are resulting in increasing language and learning skills and decreasing problem behaviors, and being stuck with old protocols not individualized enough is not going to help kids reach their fullest potential.

My goal for every client or even from my typical son or any typical kids out there, is that they each be as safe as possible, as independent possible, and as happy as possible. And I think we can do that by implementing verbal behavior procedures and collaborating and training and working with parents to make home school, community, everything merge so that children are making gains in all areas and are reaching their fullest potential in all areas.

I don’t see that when people stick to a certain methodology at school only. That’s pretty secretive about what you’re doing and how it’s working, and so I think the verbal behavior approach that The ABBLS being commercially available and now the BB mapping commercially available I think has done a real service to helping kids because it’s gotten procedures and techniques available to parents who are a huge stakeholder in this and are usually the biggest advocates.

So overall in summary, there are key differences between a Lovaas ABA approach and a verbal behavior approach. With the verbal behavior approach, we focus right away on expressive language and we do it based on the verbal operants with assessment and careful programming. There’s a heavy focus on pairing and manding and wanting kids to want to be with us, to want to run to the table, not to get away from us.

We use errorless teaching. Not a no, no prompt procedure which used to be, I’m not sure if that’s still what the institute uses, but we use an errorless teaching approach so there is less stressed because there’s less errors and we use an individualized verbal behavior assessment. So, each assessment is we take a look at strengths and needs, and we really analyze language to the fullest extent possible. There’s also usually with a BB approach, we use cold probe data instead of trial by trial data. So, there’s usually a lot less data collection and more time for teaching and those are some of the key differences.

I’m sure I missed some and we also, I wholeheartedly agree that we need more research and on the use of the verbal behavior approach and I would encourage researchers who might be listening to collaborate with both practitioners and parents who are reporting good transformations because like myself and other practitioners may not have the time and the resources to do controlled research and we need to build a village to help get the research done so that everyone’s ABA treatment can be as good as possible.

So, if you would like any of the show notes, we will have some links to some different resources. You can go to Marybarbera.com/five. And if you would like more information about my online courses community, the verbal behavior approach in general, you can go to Marybarbera.com/workshops to sign up for our free workshop. I hope you enjoyed this show. If you did, please leave me a comment or a review, share the episode and definitely subscribe so you don’t miss any episodes and I’ll be back here next week.

Thanks for listening to the Turn Autism around podcast with Dr. Mary Barbera. To join Mary’s mission to turn autism around for 2 million by 2020, go to MaryBarbera.com/join.