Skip to main content
Log in

Ethical Issues in ABA-based Service Provision for Autism in Limited-Resource Contexts: A Case Example of the People’s Republic of China

  • Discussion and Review Paper
  • Published:
Behavior Analysis in Practice Aims and scope Submit manuscript

Abstract

Recommendations for intervention for young children with autism spectrum disorders (ASD) focus on early, intensive, and often individual intervention based on methods of applied behavior analysis. In much of the world, there are few options for early intervention. This article examines this question: in a context where intensive and high staff-to-student ratio intervention is not possible, how can provision of high-quality evidence-based intervention be ensured? We consider the case of China, where intervention for young children with autism is provided at diverse educational organizations, and funding limitations impact teacher-to-student ratio. Due to challenges, rigorous use of evidence-based methods often lags behind best practices. This article presents an ethical analysis of the choices educators face and research-based recommendations consistent with the ethical analysis. Given the current context, we recommend a socially valid approach of systematically using group instruction based on ABA principles to increase the effectiveness and intensity of each aspect of intervention programs. While focused on the case of China, recommendations and analysis have implications for other settings with limited resources.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

Data Availability

n/a.

References

  • Adamson, R. M., & Lewis, T. J. (2017). A comparison of three opportunity-to-respond strategies on the academic engaged time among high school students who present challenging behavior. Behavioral Disorders, 42(2), 41–51.

    Article  Google Scholar 

  • Aristotle. (2009). The Nicomachean ethics (W.D. Ross & L. Brown, Eds). Oxford University Press. (original work published ca. 330 B.C.).

  • Behavior Analyst Certification Board (BACB). (2014). Professional and ethical compliance code for behavior analysts.

  • Boutot, E. A., & Hume, K. (2012). Beyond time out and table time: Today’s Applied Behavior Analysis for students with autism. Education and Training in Autism and Developmental Disabilities, 47(1), 23–38.

    Google Scholar 

  • Charania, S. M., LeBlanc, L. A., Sabanathan, N., Ktaech, I. A., Carr, J. E., & Gunby, K. (2010). Teaching effective hand-raising to children with autism during group instruction. Journal of Applied Behavior Analysis, 43, 493–497.

    Article  PubMed  PubMed Central  Google Scholar 

  • Chen, X. Y., & Cheng, J. (2020). 我国孤独症谱系障碍儿童康复定点机构干预方法使用现状的调查 [Investigation on the use of intervention methods in designated rehabilitation institutions for children with autism spectrum disorder in China]. 中国康复医学杂志, 035(005), 590–594. https://doi.org/10.3969/j.issn.1001-1242.2020.05.015

    Article  Google Scholar 

  • Chen, J., Zhang, J., & Li, X. (2003). 个体化训练对30例儿童孤独症治疗的观察[Individual Training for Children with Autism]. 中国心理卫生杂志, 17(2), 130–132.

    Google Scholar 

  • China Disabled Persons’ Federation. (2021). 2020年残疾人事业发展统计公报 [2020 Statistical Bulletin on the Development of Disabled Persons]. Available at: https://www.cdpf.org.cn/zwgk/zccx/tjgb/d4baf2be2102461e96259fdf13852841.htm

  • Codding, R. S., & Lane, K. L. (2015). A spotlight on treatment intensity: An important and often overlooked component of intervention inquiry. Journal of Behavioral Education, 24, 1–10. https://doi.org/10.1007/s10864-014-9210-z

    Article  Google Scholar 

  • Common, E. A., Lane, K. L., Cantwell, E. D., Brunsting, N. C., Oakes, W. P., Germer, K. A., & Bross, L. A. (2020). Teacher-delivered strategies to increase students’ opportunities to respond: A systematic methodological review. Behavioral Disorders, 45(2), 67–84.

  • Daniels, N. (2006). Equity and population health: Toward a broader bioethics agenda. The Hastings Center Report, 36(4), 22–35. https://doi.org/10.1353/hcr.2006.0058

    Article  PubMed  Google Scholar 

  • Dawson, G., & Bernier, R. (2013). A quarter century of progress on the early detection and treatment of autism spectrum disorder. Development and Psychopathology, 25, 1455–1472.

    Article  PubMed  Google Scholar 

  • Dawson, G., Rogers, S., Munson, J., Smith, M., Winter, J., Greenson, J., Donaldson, A., & Varley, J. (2010). Randomized, controlled trial of an intervention for toddlers with autism: The Early Start Denver Model. Pediatrics, 125(1), e17–e23. https://doi.org/10.1542/peds.2009-0958

    Article  PubMed  Google Scholar 

  • Doke, L. A., & Risley, T. R. (1972). The organization of day-care environments: Required vs. optional activities. Journal of Applied Behavior Analysis, 5, 405–420.

    Article  PubMed  PubMed Central  Google Scholar 

  • Eikeseth, S., Smith, T., Jahr, E., & Eldevik, S. (2002). Intensive behavioral intervention at school for 4-to 7-year-old children with autism. Behavior Modification, 26, 49–68.

    Article  PubMed  Google Scholar 

  • Eikeseth, S., Smith, T., Jahr, E., & Eldevik, S. (2007). Outcome for children with autism who began intensive behavioral intervention between ages 4 and 7: A comparison controlled study. Behavior Modification, 31, 264–278.

    Article  PubMed  Google Scholar 

  • Feng, J. R., & Wei, S. H. (2018). 康复机构孤独症儿童陪读家长心理弹性调查研究 (A study on psychological resilience of parents accompanying autistic children in rehabilitation institutions). 现代特殊教育(Journal of Modern Special Education), 11, 38–43.

    Google Scholar 

  • Garbutt, G., & Davies, P. (2011). Should the practice of medicine be a deontological or utilitarian enterprise? Journal of Medical Ethics, 37(5), 267–270. https://doi.org/10.1136/jme.2010.03611

    Article  PubMed  Google Scholar 

  • Guo, Y. Q. (2006). Training parents and professionals to help children with autism in China: The contribution of behaviour analysis. International Journal of Psychology, 41, 523–526.

    Article  Google Scholar 

  • Haydon, T., Macsuga-Gage, A. S., Simonsen, B., & Hawkins, R. (2012). Opportunities to respond: A key component of effective instruction. Beyond Behavior, 22(1), 23–31. https://doi.org/10.1177/107429561202200105

  • Heward, W. L., Gardner, R., Cavanaugh, R. A., Courson, F. H., Grossi, T. A., & Barbetta, P. M. (1996). Everyone participates in this class: Using response cards to increase active student response. Teaching Exceptional Children, 28(2), 4–10.

    Article  Google Scholar 

  • Hou, Z. (1995). 儿童孤独症的临床特征及矫正模式[Clinical Features and Modification Model of Childhood Autism]. 心理发展与教育, (04), 55–58.

  • Hume, D. (1998). An enquiry concerning the principles of morals (T.L. Beauchamp, Ed.). Oxford University Press. (original work published 1751).

  • Kant, I. (1964). Groundwork of the Metaphysic of Morals (H.J. Paton, trans.). Harper and Row. (Original work published 1785).

  • Lamb, E. (2019). A balanced view on ABA therapy, by an autistic adult. The Autism Café. Available at https://theautismcafe.com/a-balanced-view-on-aba-therapy-by-an-autistic-adult/ Retrieved January 8, 2022

  • Leaf, R. B., Taubman, M. T., McEachin, J. J., Leaf, J. B., & Tsuji, K. H. (2011). A program description of a community-based intensive behavioral intervention program for individuals with Autism Spectrum Disorders. Education And Treatment Of Children, 34(2), 259–285.

    Article  Google Scholar 

  • Leaf, J. B., Tsuji, K. H., Lentell, A. E., Dale, S. E., Kassardjian, A., Taubman, M., McEachin, J., Leaf, R., & Oppenheim-Leaf, M. L. (2013). A comparison of Discrete Trial Teaching implemented in a one-to-one instructional format and in a group instructional format. Behavioral Interventions, 28, 82–106. https://doi.org/10.1002/bin.1357

    Article  Google Scholar 

  • Li, X. (2019). 我国面向自闭症者及家庭的社会政策:议程及展望[Social Policy for People with Autism and Families: Agenda and Prospects]. 社会福利(理论版), (10),12–18.

  • Liao, Y., Dillenburger, K., & Buchanan, I. (2018). Does culture matter in ABA-based autism interventions? Parent and professional experiences in the UK and China. European Journal of Behavior Analysis, 19(1), 11–29. https://doi.org/10.1080/15021149.2017.1399657

    Article  Google Scholar 

  • Linstead, E., Dixon, D. R., French, R., Granpeesheh, D., Adams, H., German, R., Powell, A., Stevens, E., Tarbox, J., & Kornack, J. (2017). Intensity and learning outcomes in the treatment of children with autism spectrum disorder. Behavior Modification, 41(2), 229–252. https://doi.org/10.1177/0145445516667059

    Article  PubMed  Google Scholar 

  • Liu, M. H., & Zhao, Y. S. (2019). 应用行为分析法对孤独症儿童社会交往能力干预效果的研究 [A study on the intervention effectiveness of Applied Behavior Analysis on social interaction skills of children with autism]. 按摩与康复医学, 10(18), 50–53.

    PubMed  Google Scholar 

  • Liu, Q., Hsieh, W. Y., & Chen, G. W. (2020). A systematic review and meta-analysis of parent-mediated intervention for children and adolescents with autism spectrum disorder in mainland China, Hong Kong, and Taiwan. Autism, 24(8), 1960–1979.

    Article  PubMed  Google Scholar 

  • Liu, Yao, & X., Wang, M., & Du, L. (2020). Academic support for students with developmental disabilities in elementary schools: the roles and experiences of Chinese classroom teachers. International Journal of Developmental Disabilities, 66(1), 1–12. https://doi.org/10.1080/20473869.2019.1653659.

    Article  Google Scholar 

  • Locke, J. (1980). Second treatise of government . C. B. Macpherson, Ed. Hackett Publishing. (original work published 1689).

  • Lotfizadeh, A. D., Kazemi, E., Pompa-Craven, P., & Eldevik, S. (2020). Moderate effects of low intensity behavioral intervention. Behavior Modification, 44(1), 92–113. https://doi.org/10.1177/0145445518796204

    Article  PubMed  Google Scholar 

  • Lovaas, O. I. (1987). Behavioral treatment and normal educational and intellectual functioning in young autistic children. Journal of Consulting and Clinical Psychology, 55(1), 3–9.

    Article  PubMed  Google Scholar 

  • McCabe, H. (2008a). Two decades of serving children with autism in the People’s Republic of China: Achievements and challenges of a state-run mental health center. Disability and Society, 23(3), 271–282.

    Article  Google Scholar 

  • McCabe, H. (2008b). The importance of parent-to-parent support among families of children with autism in the People’s Republic of China. International Journal of Disability, Development, and Education, 55(4), 303–314.

    Article  Google Scholar 

  • McCabe, H. (2013). Bamboo shoots after the rain: Development and challenges of autism intervention in China. Autism: The International Journal of Research and Practice, 17(5), 510–526.

    Article  PubMed  Google Scholar 

  • McCabe, H., & Deng, G. (2018). “So they’ll have somewhere to go”: Establishing Non-governmental organizations (NGOs) for children with autism in the People’s Republic of China. Voluntas: International Journal of Voluntary and Non-profit Organizations, 29(5), 1019–1032. https://doi.org/10.1007/s11266-017-9879-4

    Article  Google Scholar 

  • McCabe, H., & Tian, H. (2001). Early intervention for children with autism in the People’s Republic of China: A focus on parent training. The Journal of International Special Needs Education, 4, 39–43.

    Google Scholar 

  • Menzel, P. (2007). Allocation of scarce resources (pp. 305–322). Blackwell Publishing Ltd.. https://doi.org/10.1002/9780470690932.ch17

    Book  Google Scholar 

  • National Autism Center. (2015). Findings and conclusions: National standards project, phase 2. Author.

    Google Scholar 

  • Owiny, R. L., Spriggs, A. D., Sartini, E. C., & Mills, J. R. (2018). Evaluating response cards as evidence based. Preventing School Failure, 62(2), 59–72. https://doi.org/10.1080/1045988X.2017.1344953

    Article  Google Scholar 

  • Pellecchia, M., Iadarola, S., & Stahmer, A. C. (2019). How meaningful is more? considerations regarding intensity in early intensive behavioral intervention. Autism: The International Journal of Research & Practice, 23(5), 1075–1078. https://doi.org/10.1177/1362361319854844

    Article  Google Scholar 

  • Pennington, R. C., & Courtade, G. R. (2015). An examination of teacher and student behaviors in classrooms for students with moderate and severe intellectual disability. Preventing School Failure, 59(1), 40–47. https://doi.org/10.1080/1045988X.2014.919141

    Article  Google Scholar 

  • Peters-Scheffer, N., Didden, R., Mulders, M., & Korzilius, H. (2013). Effectiveness of low intensity behavioral treatment for children with autism spectrum disorder and intellectual disability. Research in Autism Spectrum Disorders, 7(9), 1012–1025. https://doi.org/10.1016/j.rasd.2013.05.001.

    Article  Google Scholar 

  • Qu, X. (2021). Structural barriers to inclusive education for children with special educational needs and disabilities in China. Journal of Educational Change. https://doi.org/10.1007/s10833-021-09426-2.

    Article  Google Scholar 

  • Randolph, J. J. (2007). Meta-analysis of the research on response cards: Effects on test achievement, quiz achievement, participation, and off-task behavior. Journal of Positive Behavior Interventions, 9(2), 113–128.

    Article  Google Scholar 

  • Reed, P., Osborne, L. A., & Corness, M. (2007). Brief report: Relative effectiveness of different home-based behavioral approaches to early teaching intervention. Journal of Autism and Developmental Disorders, 37, 1815–1821. https://doi.org/10.1007/s10803-006-0306-8

    Article  PubMed  Google Scholar 

  • Rehfeldt, R. A. (2011). Toward a technology of derived stimulus relations: An analysis of articles published in the Journal of Applied Behavior Analysis, 1992–2009. Journal of Applied Behavior Analysis, 44(1), 109–119. https://doi.org/10.1901/jaba.2011.44-109

    Article  PubMed  PubMed Central  Google Scholar 

  • Reichow, B. (2012). Overview of meta-analyses on early intensive behavioral intervention for young children with autism spectrum disorders. Journal of Autism and Developmental Disorders, 42, 512–520. https://doi.org/10.1007/s10803-011-1218-9

    Article  PubMed  Google Scholar 

  • Rivard, M., Morin, M., Mello, C., Terroux, A., & Mercier, C. (2019). Follow up of children with autism spectrum disorder 1 year after early behavioral intervention. Behavior Modification, 43(4), 490–517. https://doi.org/10.1177/0145445518773692

    Article  PubMed  Google Scholar 

  • Shieh, S., & Deng, G. (2011). An emerging civil society: The impact of the 2008 Sichuan Earthquake on grassroots associations in China. The China Journal, 65, 182–194.

    Article  Google Scholar 

  • Spangler, P. F., & Marshall, A. M. (1983). The unit play manager as facilitator of purposeful activities among institutionalized profoundly and severely retarded boys. Journal of Applied Behavior Analysis, 16(3), 345–349.

    Article  PubMed  PubMed Central  Google Scholar 

  • State Council. (2015). 国务院关于加快推进残疾人小康进程的意见 [Suggestion of The State Council on Accelerating the Well-off Process of People with Disabilities]. Available at: http://www.gov.cn/zhengce/content/2015-02/05/content_9461.htm

  • Steinbrenner, J. R., Hume, K., Odom, S. L., Morin, K. L., Nowell, S. W., Tomaszewski, B., Szendrey, S., McIntyre, N. S., Yücesoy-Özkan, S., & Savage, M. N. (2020). Evidence-based practices for children, youth, and young adults with Autism. The University of North Carolina at Chapel Hill, FPG Child Development Institute, National Clearinghouse on Autism Evidence and Practice Review Team.

    Google Scholar 

  • Stephenson, J. (2006). Response cards: Increasing individual responding during whole-class teaching. Australian Journal of Learning Difficulties, 11(2), 57–62. https://doi.org/10.1080/19404150609546808

    Article  Google Scholar 

  • Sun, X., Allison, C., Auyeung, B., Matthews, Murray, S., Baron-Cohen, S., & Brayne, C. (2013). Service provision for autism in mainland China: A service providers’ perspective. Research in Developmental Disabilities, 34, 440–451.

  • Sun, X., Allison, C., Wei, L., Matthews, F. E., Auyeung, B., Wu, Y. Y., Griffiths, S., Zhang, J., Baron-Cohen, S., & Brayne, C. (2019). Autism prevalence in China is comparable to Western prevalence. Molecular Autism, 10(7), 1–19. https://doi.org/10.1186/s13229-018-0246-0

    Article  Google Scholar 

  • Sundberg, M. L. (2014). VB-MAPP. Verbal Behavior Milestones Assessment and Placement Program (2nd ed.). AVB Press.

    Google Scholar 

  • Taubman, M., Brierley, S., Wishner, J., Baker, D., McEachin, J., & Leaf, R. B. (2001). The effectiveness of a group discrete trial instructional approach for preschoolers with developmental disabilities. Research in Developmental Disabilities, 22, 205–219.

    Article  PubMed  Google Scholar 

  • Thompson, J. L., Wood, C. L., Preston, A., & Stevenson, B. (2019). Teaching unison responding during small-group direct instruction to students with autism spectrum disorder who exhibit interfering behaviors. Education and Treatment of Children, 42(1), 1–24.

    Article  Google Scholar 

  • Trump, C. E., Pennington, R. C., Travers, J. C., Ringdahl, J. E., Whiteside, E. E., & Ayres, K. M. (2018). Applied Behavior Analysis in special education: Misconceptions and guidelines for use. Teaching Exceptional Children, 50(6), 381–393. https://doi.org/10.1177/0040059918775020

    Article  Google Scholar 

  • Vietze, P., & Lax, L. E. (2020). Early intervention ABA for toddlers with ASD: Effect of age and amount. Current Psychology, 39, 1234–1244. https://doi.org/10.1007/s12144-018-9812-z

    Article  Google Scholar 

  • Waddington, H., van der Meer, L., Sigafoos, J., & Ogilvie, E. (2020). Evaluation of a low-intensity version of the early start Denver model with four preschool-aged boys with autism spectrum disorder. International Journal of Developmental Disabilities, 66(4), 257–269. https://doi.org/10.1080/20473869.2019.1569360

    Article  Google Scholar 

  • Wang, P. (2008). Effects of a parent training program on the interactive skills of parents of children with autism in China. Journal of Policy and Practice in Intellectual Disabilities, 5(2), 96–104.

    Article  Google Scholar 

  • Wang, Q. C. (2021). 行为分析疗法联合早期丹佛模式的教学 对孤独症患儿康复的影响 [The impact of behavior analysis treatment and Early Start Denver Model on children with autism], 医学理论与实践. 34, (11), 1966–1968.

  • Warren, S. F., Fey, M. E., & Yoder, P. J. (2007). Differential treatment intensity research: A missing link to creating optimally effective communication interventions. Mental Retardation and Developmental Disabilities Research Reviews, 13, 70–77. https://doi.org/10.1002/mrdd.20139

    Article  PubMed  Google Scholar 

  • WHO. (2021). Autism Spectrum Disorders. Fact Sheet. World Health Organization, Retrieved October 11, 2021 from https://www.who.int/news-room/fact-sheets/detail/autism-spectrum-disorders

  • Wolf, M. M. (1978). Social validity: The case for subjective measurement. or How Applied Behavior Analysis is finding its heart. Journal of Applied Behavior Analysis, 11(2), 203–214.

    Article  PubMed  PubMed Central  Google Scholar 

  • Yan, J., Zhuang, X. X., & Chen, J. (2020). 学前特殊儿童家庭康复调查研究 [The Survey on Familial Rehabilitation of Preschool Special Children]. 陕西学前师范学院学报, 36(6), 114–119.

    PubMed  Google Scholar 

  • Yoder, P. J., & Woynaroski, T. (2015). How to study the influence of intensity of treatment on generalized skill and knowledge acquisition in students with disabilities. Journal of Behavioral Education, 24(1), 152–166. https://doi.org/10.1007/s10864-014-9216-6

    Article  PubMed  Google Scholar 

  • Zou, B., Ke, X., Hong, S., Hang, Y., Chen, Y., Chen, X., & Wang, M. (2008). 家长应用回合式教学法训练孤独障碍儿童的疗效研究[Analysis on the Efficiency of Discrete Trial Teaching for Autistic Children Used by Parents]. 中国心理卫生杂志, 9, 634–636,665.

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Helen McCabe.

Ethics declarations

Conflicts of Interest/Competing Interests

None.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

McCabe, H., Barnes, R.E. & Jiang, T. Ethical Issues in ABA-based Service Provision for Autism in Limited-Resource Contexts: A Case Example of the People’s Republic of China. Behav Analysis Practice 16, 40–50 (2023). https://doi.org/10.1007/s40617-022-00692-x

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40617-022-00692-x

Keywords

Navigation