Occupational therapy was used as a method of training people with autism and mental disabilities to independently perform normal activities of daily living (ADLs) long before applied behavior analysis ever came onto the scene. It was also used to promote functional independence among autistic individuals before autism itself was even identified as a specific disorder.
Over the years the therapeutic methods have been refined and, even the attitudes with which therapists approach the work has evolved. Originally seen as a solution to an individual’s lack of productivity, today occupational therapy is implemented to improve quality of life and skills training for the disabled.
Now that applied behavior analysis has come on the scene and made its mark as an extremely effective evidence-based treatment for Autism Spectrum Disorder (ASD), today both OTs and ABAs are regularly found working together in schools, clinics, and long-term care facilities, offering mutually complementary treatment to children and adults with ASD and other developmental and cognitive disorders.
Functional Aspects of Behavior Rule Both OT and ABA Approaches to ASD Treatment
There are some important similarities between OT and ABA:
- Both emphasize functional aspects of behavior and outcomes over theory.
- Both involve detailed and careful observation of patients and analysis of the environment.
- Both stress unique, individualized treatment plans rather than formulaic approaches.
- Both use a holistic analysis that considers multiple environmental factors in diagnosis and treatment.
And, of course, the big-picture goals for both OT and ABA in treating autistic individuals are the same: teach appropriate skills and behavior to improve quality of life and socialization.
This perception is not universal among either OTs or ABAs, however. OTs may dismiss concepts of behavior and consequence as only ancillary to their task-oriented approach, not realizing that ABA can be equally function-oriented. And ABAs may not credit OT approaches that do not consider consequences or environmental antecedents of problematic behaviors.
A Complementary Approach Closes the Gaps that Exist in Both ABA and OT
With the emergence of applied behavior analysis as the preferred treatment for ASD, and the scientific validation to back it up, occupational therapy has been relegated to a support role in most cutting edge treatment programs. But OT still has much to bring to the table.
A good way to think about the occupational therapy approach is to imagine it as addressing the mechanical aspects of functionality.
For example, an OT observing an autistic child having difficulty learning to write, perhaps acting out in the process, might note that the way the pen is being held is inefficient or ineffective for forming letters correctly. They might decide a different pen design is necessary, or that the child should sit differently to change the angle, or attempt to teach a different grip.
An ABA observing the same situation might determine that the underlying issue is driven by the child’s inability to communicate. Instead of focusing on the mechanics of writing, the ABA might construct an intervention plan that offers different methods of communication, or uses selective reinforcements like treats or positive verbal statements to encourage the child when they form letters properly.
Of course, neither of these approaches need to be applied in a vacuum, and can actually provide significant reinforcement to one another. Physical deficiencies in technique are a part of the antecedents that are leading to the problematic behavior that ABAs identify– a lack of motivation just can’t be solved with physical changes alone. The OT can break down the mechanical processes and limitations to make them easier to correct in ways that ABAs may be unaware of. ABAs, on the other hand, can address psychological aspects of motivation and learning that OTs typically do not focus on or attempt to alter.
This makes ABA and OT a chocolate and peanut butter solution when it comes to ASD treatment, and many therapy services are learning to incorporate both practices into their programs.
How ABA and OT Can Work Together in Autism Treatment
Some occupational therapy practices incorporate, largely inadvertently, the same sort of reinforcers that ABAs would intentionally use to influence behaviors. For example, OTs using sensory integration therapy to treat autistic children who appear obsessed with playing with certain toys or performing certain activities will often attempt to substitute actions that mimic the sensory aspects of engaging in those activities. Naturally, the substitute activities would be designed to have a better skills training application.
In one case, a three-year-old boy diagnosed with ASD exhibited significant deficits in communication and socialization, instead showing preferences for activities that involve constant motion. The occupational therapist working on the case had a swing installed in the family room, an area of the house that had always represented a location where there was no outlet for the child’s preferred activity. With the swing in place, the boy was able to satisfy his own need for constant motion while in a normal environment that allowed him to interact with family members. His socialization and communication scores improved markedly.
This, of course, is partly the result of providing a positive reinforcement to the child, whose enjoyment of constant motion will lead to choosing the replacement toy or activity (swinging) over less unpredictable and chaotic motion, an alternative that is much more conducive to family engagement in a normal environment.
The sensory view is one emphasized in OT training. Occupational therapists are task-oriented, looking at specific functions that aren’t being performed or engaged in well. ABAs, however, are behavior-oriented, looking across different tasks or situations to identify problematic behavioral issues.
Because many issues faced by ASD patients are multi-spectrum, involving both sensory and behavioral issues, it is only natural to make use of both approaches in a cross-disciplinary treatment system.
ABAs are specifically trained to look for reinforcement techniques and opportunities. Applying that training to the practice of occupational therapy as a way to increase the performance of ADLs can result in much faster improvement than using either process independently.
OTs can also benefit from the strong data collection and analysis that ABAs bring to the table. In at least one organization, ABAs conducting their Functional Behavior Analysis (FBA) share the data gathered with their OT colleagues, who can then both introduce their own treatments and gauge the efficacy as the ABA continues to make observations.
Qualifications and Training for ABAs and OTs
In addition to striving for similar goals and outcomes, the educational background for applied behavior analysts and occupational therapists are likewise similar.
ABAs must have a master’s degree or higher in a select number of fields, and almost all are required to obtain a Board Certified Behavior Analyst (BCBA®) certification from the Behavior Analyst Certification Board (BACB) in order to practice. Increasingly, they are being brought into professional licensing regimes by states across the country.
Since 2007, OTs have also been required to have a master’s degree or higher. The practice is regulated in all fifty states, the majority of which require licensure. Strong professional standards have governed the practice for more than 100 years.
Increasingly, many OTs and ABAs are obtaining a doctoral-level education in their respective fields:
- For ABAs, this is often a Ph.D. in psychology or applied behavior analysis, leading to the BCBA®-D certification.
- For OTs, it is an OTD, or Post Professional Doctor of Occupational Therapy, a practice-focused degree available to master’s-prepared occupational therapists.
Because of the difficulty of locating local doctoral program options and the inconvenience of relocating, many candidates are finding and taking advanced degree programs online.
As the standard of care for autism treatment improves, advancing educational standards will accompany it, and more and more ABAs and OTs will likely be looking at doctoral-level credentials in the future.