According to the Centers for Disease Control (CDC), autism occurs equally in all ethnic, racial, and socioeconomic groups. While some risk factors have been outlined for autism spectrum disorder (ASD), the exact cause is unknown. This information is provided by the Autism and Developmental Disabilities Monitoring (ADDM) Network, which is a part of the CDC. ADDM has been monitoring children in the United States with autism since 2000.
Because ASD can affect those across all cultures equally, it’s imperative for an ABA clinician and the practice to be well-versed in diversity, and familiar with various cultures and ethnicities. So, what does culture actually mean? The short answer is that it is an established way of life for a certain society. The textbook definition according to of culture is, “the way of life of a particular society or group of people, including patterns of thoughts, beliefs, behavior, customs, traditions, rituals, dress, language and arts, music and literature.”
It’s estimated that 1 in 44 children have an autism spectrum disorder diagnosis in the United States, which is significantly higher than it had been in previous decades, perhaps due in part to a lack of tools being available to properly spot and diagnose the disorder. Diagnosis rates in other countries are often lower, perhaps due to lack of awareness and cultural acceptance. With that high of an incidence rate in the United States, applied behavior analysis (ABA) clinicians must acquire and retain the knowledge of different cultures and ways of life in order to properly implement treatment. Read on to learn more about how clinicians can learn more about different cultures, plus some of the barriers that exist when it comes to implementing different cultural standards in treatment.
Culture from a Behavioral Perspective
Culture from a behavior analyst’s perspective includes knowing the entire range of learned human behavior and its patterns. However, that full range of knowledge should be diverse, not only having knowledge of different cultures but also having the ability to implement that knowledge into a cohesive treatment plan so it best benefits the child (and their family). Behaviorist F.S. Skinner described culture as variables that are “arranged by other people.”
Skinner also praised the value of determining a client’s cultural identity (e.g., ethnicity, race, sexual orientation, disability, nationality, socioeconomic class, age, gender, religion, geographic context), as it can help clinicians identify the client’s cultural values. This leads to the acquisition of more effective reinforcers and more individualized treatment once the clinician knows the client’s preferences. Sometimes this information must be explained by the parents and family, especially if the child is nonverbal or is unable to communicate their wants and needs (which is something ABA therapy seeks to improve). It is tough to understand a client’s wants and needs without the cultural background and knowledge of their cultural identity as a whole.
As an ABA clinician is drawing up a treatment plan, they want to ask themselves questions, such as:
- How can I best support clients of all cultural backgrounds?
- How can I help clients advocate for themselves and their needs?
- How do I support clients who, because of behavioral struggles, may have an increased likelihood of having an interaction with police or emergency personnel?
When asking these questions, it’s also vital to recognize the barriers to understanding cultural differences that are in place and how they may be overcome during the course of treatment.
As part of passing the board-certified behavior analyst (BCBA) examination, which is implemented by the Board Analyst Certification Board (BACB), an aspiring clinician must have a certain level of cultural competency, and this is a requirement for passing the BCBA exam. This can include culture, national origin, gender, race, and religion, among other things. A competent and thorough BCBA has to put their own opinions and beliefs aside, with the ability to deliver treatment to those families who don’t hold the same opinions and beliefs or have a culture that is new and unknown to the clinician. Having a good sense of one’s own cultural identity and sense of self can help bridge the gap, offering the ability to better understand those who come from different backgrounds.
Another thing to consider in this realm is what a cultural or societal norm is. What is accepted as “normal” in one culture may be considered a problem in another. As a parent, it’s essential to understand what ABA seeks to accomplish so that you can collaborate with your child’s treatment team in order to formulate a plan that’s best for your child and your family.
What Does ABA Seek to Accomplish?
If you’re reading this article, chances are you’re already at least slightly familiar with ABA therapy. However, for review, below is some information about ABA to better understand why diversity is important when practicing in the field and how a client’s cultural identity should be an integral part of the treatment plan.
In a nutshell, applied behavior therapy seeks to increase positive and helpful behaviors while decreasing problematic ones at the same time. ABA also focuses on many other aspects that may detrimentally affect a child with autism. ABA clinicians work closely with the child to help foster better communication at home, school, and out in the community, promote daily living skills and self-care, and assist in academics and learning. As a child gets older, an ABA treatment plan may shift the focus toward preparing for big transitions, such as employment or higher learning.
ABA therapy is delivered by a supervisor and a registered behavior technician (RBT), who is directly supervised by the supervisor. Both must be licensed by the state, and a supervisor must possess a master’s degree or Ph.D. in psychology or behavior.
Each treatment plan is highly individualized and tailored to each child with autism. As autism is a spectrum disorder, no two children or people with autism present in the same way. Before ABA services begin, a supervisor will conduct an assessment to determine your child’s strengths and areas that need attention. The “applied” part of applied behavior analysis implies treatments must be highly individualized. Ignoring or not being aware of culture and value differences and not implementing them in a behavior treatment plan is essentially ignoring the “applied” part of ABA. Treatment can’t be effectively applied unless all relevant information is known, including differences in culture.
While it may sound like common sense, it’s also important to ensure services are delivered in the correct language. A non-native English speaker may speak and understand English, but delivering treatment in their native language has the power to be much more effective, particularly if the native language is the primary one in the home. It is important to also take into account which language the child wishes to use, even if they are nonverbal. ABA treatments that help foster better communication are often delivered in the form of a Picture Exchange Communication System (PECS) or AAC devices, such as tablets that help a child communicate. These tools should be adapted to the language the child is most comfortable with for the best outcome.
A large part of ABA “behind the scenes” is data collection, which is performed by the supervisor and the behavior technician. The supervisor will track progress or lack thereof, antecedents, behaviors, and consequences, and motivators, among other data points. This data collection is then used to implement certain therapies within treatment or to adjust treatment goals. If culture isn’t considered when collecting data, this can affect the effectiveness of the treatment plan, and the correct therapies may not be delivered, despite the clinician’s best intentions.
ABA, in itself, is its own culture and is a westernized model. As such, clinicians may have a tendency to stick solely to the westernized delivery of ABA, unintentionally ignoring cultural differences and practices. Bollinig wrote in the Journal of Behavior and Social Issues in 2002:
“It is difficult for people in the US cultural mainstream, including researchers, to believe that there are any assumptions other than their own about how the world works, what a ‘person’ is, how we function, how time works, what feelings are, how to use language, what the goal of life is, how people interrelate, [and] how and where it is appropriate to show feelings or to seek help.”
ABA clinicians are not expected to be familiar with every language and culture, of course—the expectation lies more in recognizing the wants and needs of the child and the family as a whole and seeking to implement a plan that reflects those cultural values. There is always room to be teachable. According to the University of Oregon, Cultural Humility is “a practice of self-reflection on how one’s own background and the background of others, impact teaching, learning, research, creative activity, engagement, leadership, etc.” Even is a supervisor or behavior technician doesn’t identify with the same culture as the child, having cultural humility to develop an understanding of not knowing what they don’t know, learning and adapting, is a critical aspect of treatment.
Part of the issue when it comes to determining a client’s cultural identity or coming to a place of cultural understanding is the lack of research and lack of guidelines when it comes to ABA therapy and cultural diversity.
Roadblocks to Understanding Cultural Differences in ABA
It’s easy to fault the clinician if cultural differences are not recognized or understood, but there is an issue as a whole in the ABA community and related research. First, there is a distinct lack of research regarding the diversity of clinicians in the ABA community. Many practices do not share demographic information, which is understandable but not helpful. In order to better serve the community as a whole, it would be valuable to know more about the diversity of practitioners so relevant staff can be matched with the clients and families that need them. For example, if there is a distinct need for Spanish-speaking clinicians in a community but no direct evidence as proof, quality of care can be lacking if English-speaking programming is delivered.
There is also a lack of research on how cultural diversity and differences and ABA interact as a whole. Obviously, more cultural understanding will lead to better treatment outcomes. However, just as with clinicians, demographic information of clients is not readily available, so it can be difficult to discern where more education/training is needed.
ABA clinicians must also perform 32 units of Continuing Education Units (CEUs) every two years; however, there is currently no CEU requirement in place for cultural diversity, even though a basic understanding is required for the board certification. Clinicians must be proactive on their own in order to better understand the cultural needs of their clients and families. It would be much more advantageous if there was a clear requirement for cultural competency. But, the lack of CEUs and clear requirements may also be due to a lack of research.
Overcoming Roadblocks in Cultural Competency
So, how can an ABA clinician overcome some of these roadblocks for better client success? In the 2016 article Developing the Cultural Awareness Skills of Behavior Analysts, there are several recommendations analysts and practices can follow in order to better serve their clients. Some of these include:
- Diversity of resources. ABA clinicians regularly bring tools in-home in order to work with children with autism. It’s important to ensure resources are tailored to the child’s cultural needs. This is especially important when it comes to language—therapy will be less effective if, for example, a clinician brings only materials in English to a non-native-speaking or communicating child.
- Understanding cultural identity of self. Clinicians that are in touch with their own cultural identities, including biases, allow them to grow and be culturally competent with others.
- Recognizing language barriers. If there is a language barrier, it can be difficult to deliver treatment. A clinician should reach out for help within their practice to find ways to deliver treatment that are more language-specific to the family.
- Actively discover the family’s worldview. Assessment doesn’t stop at an initial assessment—in other words, as a clinician begins to work with a family and child, they should be intuitively sensitive to cultural differences to try to create a more individualized plan, and a clinician should speak with a family about their worldview, culture, and values to gain a better understanding.
Overcoming roadblocks and being culturally competent with clients can allow ABA clinicians to deliver the best quality treatment, which fosters more positive behavior outcomes that benefit both the child and their family.