In one of my last posts I referenced NDBIs and how I kind of think of them as "second generation ABA therapies." I want to break that down a little further in this post, to explain my understanding of what an NDBI is and what some of the improvements are from more traditional or "first generation" ABA therapies.
First, let's learn the broad definition for what an NDBI is. NDBI's combine the behavioral teaching strategies of ABA (a behavior that is rewarded will continue and increase in how often it happens, a behavior that is not rewarded will go away) with what we know about child development (how long is it appropriate for a child to attend to a task, the importance of motivation and child directed play etc.). There are many different kinds of therapy that fall under the category of being an NDBI. Such as:
I'm most familiar with Pivotal Response Training so I'll use that example below in discussing some of the differences between traditional ABA and NDBI's.
Why are NDBIs different?
They take into account the things that kids actually want to be doing and what it's developmentally appropriate for them to be doing.
Most NDBIs are all about increasing kids motivation to learn to do things like communicate with others and that's done by paying attention to things that kids want to do. These things could include engaging with a special interest, movement based stims, or playing with favorite toys. I think there's a sweet spot in terms of picking what activities to do this kind of intervention with. We want it to be interesting enough to the child that the child is willing to work on something that's challenging for them instead of giving up and walking away, but not so important to them that it's cruel to withhold it.
The way that most NDBIs work, the therapist/parent/caregiver get's some shared control of what the child is interested in. If the child seems interested in or is attending to this item or activity the therapist/parent/caregiver then models how the child can communicate that they'd like the item or like to the do activity in an effective way. One of the things I like best about NDBIs is that you can count attempts. In my experience ABA therapies like Discrete Trial Training (DTT) won't accept approximations, it has to be the exact response that's been agreed upon as the goal. I love that in NDBIs there's emphasis on honoring honest attempts at a new school. Describing this though, I think that you can see that this kind of teaching strategy makes sense if a child wants to play with a car but not if they need a drink of water or if they need to access a coping skill like a movement stim in an emotionally intense moment. NDBIs really emphasize choosing the best moments for teaching and that involves making sure the child is calm and in a good headspace to learn. If they're desperately trying to down regulate, prompting them to ask for their headphones is not going to fly. But if they're fed, rested, and chilling at the park wanting some spins on the swing that might be a great time to learn words like "spin", "fast", "slow", "stop", "go" etc. (in spoken, sign or AAC).
The reinforcers (rewards) make sense.
Another big area of concern in DTT is the seeming randomness of the reinforcers. For example, a child might correctly identify the color green and be given a pretzel as a reward even though pretzels having nothing to do with the color green (or, you know, so we hope.) In reality, these rewards aren't random. Since DTT doesn't engage the child's motivation by allowing them to select the activity, they need some way to motivate the child and so often these items, foods, or activities are carefully selected via something called a "preference assessment" to learn what items or activities a child likes the best. These items are then used to motivate kids to learn things like identifying colors, and numbers, math, reading, writing, and daily living skills. A common criticism of this practice is that it treats human children more like animals who are receiving a treat for getting a trick.
A feel a mixed sort of way about this. Honestly, humans are animals and trust and believe I'm not really doing anything at the end of the day unless I get some kind of treat for it. And often for me that treat is food! As I write this I'm acutely aware that I've promised myself an apple turnover once I finish this blog post (granted, I think having all your learning linked to food makes for a weird relationship with food.) But I digress... NDBIs often stress the importance of the reward being natural to the situation. For example, if a child communicates 'red' then they might be requesting an apple, or to go down a red slide, or something that actually has to do with the communication they're offering. If they're learning numbers and identify '2' they may access two of something- like two blows on the bubble wand. In NDBIs children are learning to link their communication to it's real world correlates, just like we all do when we're learning language.
There's room for comfort.
As I've said in other posts, this is my biggest issue with ABA. Due to the emphasis on planned ignoring for "problem behavior" at it's extreme ABA can create a world for kids where they effectively don't exist unless they're on their best behavior. And that sounds like a really difficult world to grow up in. And we know from research other therapies like Dialectical Behavior Therapy (DBT) that sensitive children who grow up in an "emotionally invalidating environment" are at much higher risk for mental illness like Borderline Personality Disorder (BPD). Given this, I like the room the many NDBIs provide for comfort of an upset child. As with any child, rules, boundaries and expectations are important for an Autistic child. So if you set the expectation that they use a communication skill that they've gotten good at to ask for something and it leads to a meltdown, fine maybe you don't give them that item. You haven't reinforced the not so adaptive behavior because they haven't been able to use the behavior to get the item. But in traditional ABA you would then be asked to totally ignore them until they settled down. In NDBI you can comfort them, ask them what's going on, snuggle them, offer them a sensory coping tool like a weighted blanket. I think it's a nice balance of, "we don't scream and cry to get what we want" (which is a lesson all kids need to learn) with "but when you scream or cry adults see that something is wrong and want to figure out how to help."
And I know, I know, it's complicated because sometimes the thing the child is after is attention and how do you comfort without providing attention etc...I'm not saying planned ignoring doesn't have it's place (like, when I'm babysitting and you're lying on the floor screaming because I've said no to a fourth scoop of ice cream and offered to put your favorite movie on instead, my sympathy for you is limited) it's just not always the answer. NDBIs allow space for comfort and validation (which is so so important to healthy emotional development) to be a part of the therapeutic picture.
Final Thoughts
All in all, I hope this provides some insight into why I always recommend this sort of intervention before older kinds of interventions when a family is interested in ABA or think behavioral therapy might be needed for a family or child. Unfortunately, these kinds of therapies, being newer, are not as easy to access as more traditional ABA. I've been born and raised in Virginia so below are some resources for Virginia families trying to access these kinds of therapies:
Spectrum Transformation Group (Early Start Denver Model)
Children's Specialty Group (Early Start Denver Model)
Dr. Cara Goodwin (Early Start Denver Model)
Autism Outreach Inc. (Pivotal Response Training)
Acorn Health (Pivotal Response Training)
Behavior Frontiers (Pivotal Response Training)
Sparks (Pivotal Response Training)
Kindling Behavior Consultants (Pivotal Response Training)
***Note, I'm not personally recommending any of these places! I have not worked with any of them myself. I've just done the googling and compiling so you don't have to! For advice on evaluating a provider and making sure they're a good fit check out this Resource Guide (pg. 11) from Virginia Tech Center for Autism Research. This also isn't an exhaustive list! There may be more great resources out their! Feel free to contact me if there's one you'd like me to add.
Early Start Denver Model also keeps a list of certified providers in many states!
Some NDBIs like Reciprocal Imitation Training, and Joint Attention, Symbolic Play, Engagement and Regulation haven't quite made their way out of the Ivory Tower yet, and some are only available in certain facilities (i.e., the TEACCH facilities in North Carolina).
I hope to be able to provide more resources for other states some day soon!
Until next time!
Ashley
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