Using the ADDIE Model of Instructional Design to Create Programming for Comprehensive ABA Treatment

Abstract

ABA research abounds with articles on increasing or decreasing a small set of behaviors. These articles fit nicely within the framework of Focused ABA Treatment in which the goal of treatment centers on only a few behaviors. However, many behavioral practitioners spend most of their time developing Comprehensive ABA Treatment in which a large number of behaviors are systematically changed across multiple developmental domains. Few resources are available to help in designing and implementing such programming. This article presents a model from the field of instructional design for the development of comprehensive programming. Applying the ADDIE model—Analyze, Design, Develop, Implement, Evaluate—the article identifies a consistent process to follow, critical actions to take, and helpful resources to use when developing comprehensive programming for individuals with autism.

Applied behavior analysis has identified how to effectively teach many individuals with autism (Frazier et al., 2021; Fuller & Kaiser, 2020; Greenspan et al., 2008; Hampton & Kaiser, 2016; Makrygianni et al., 2018; Smith et al., 2021). Still, behavioral practitioners must then combine how to teach with what to teach and when to teach it. This may be less of an issue in Focused ABA Treatment when only a few deficits need help, but it becomes much more complicated in Comprehensive ABA Treatment where a large number of deficits are in need of remediation (Council of Autism Service Providers, 2020). Dixon et al. (2017) note the lack of assessments and curricula that coherently merge what is assessed and what is taught. The word “curriculum” sometimes describes a final product, such as a course sequence, lesson plans, or academic book. Curriculum more broadly describes the entire process for learning development to include teaching strategies, materials, and evaluations. Shepley and Grisham-Brown (2019) provide one curriculum framework for guiding instructional decisions and identify ways in which the framework is applicable to the work of behavior analysts involved in early childhood education. As an illustration, they use a picture of an umbrella to emphasize assessment, scope and sequence, activities and instruction, and progress monitoring as the four key parts of the umbrella’s canopy. They then discuss ways in which behavior analysts can contribute to these instructional design elements in collaboration with early childhood educators.

Instructional design is an area of research that focuses on the systems and processes that are used to develop education and training programs (Gustafson & Branch, 2002). Often utilized in the fields of education and computer technology (Göksu et al., 2017), it has also been applied in fields as diverse as business (Larsson & Lockee, 2004) and medicine (Cheung, 2016). The basic framework of most instructional design models is the ADDIE model (Göksu et al., 2017; Gustafson, 2002). ADDIE stands for analyze, design, develop, implement, and evaluate. A literature review of research trends in instructional design by Göksu et al. (2017) found that the use of the ADDIE model increased learning and improved academic success. Whereas the ADDIE model identifies the major components of instructional design and serves as a basic template, many additional instructional design models emphasize what to do both within each component and across components (Gustafson & Branch, 2002). Figure 1 displays some examples. One depiction treats the ADDIE model as a stepwise, ordered sequence with a clear beginning and end. A second depiction treats the ADDIE model as a circular process, with no beginning or end. A third depiction treats the ADDIE model as a circular process with one major focus.

Fig. 1.

Different Depictions of the ADDIE (Analyze, Design, Develop, Implement, Evaluate) Model

For behavioral practitioners, the third depiction of ADDIE may be the most helpful, particularly with evaluation as the central focus. First, a circular process appears most pragmatic because everyone comes to the development of Comprehensive ABA Treatment from a different background with different levels of experience in each part of the process. For example, one behavioral practitioner may be familiar with developing early intervention programming by using a variety of strategies to include both discrete trial teaching as well as naturalistic teaching procedures. Another behavioral practitioner may have spent more time in graduate school learning to train staff to implement discrete trial teaching for a research project and then to evaluate the procedure for treatment fidelity. Second, a circular process seems applicable because improvement within one instructional design component may often have consequences for other parts of the process. For instance, someone who sets out to improve the way they design programming by being more intentional about the scope and sequence they create may find that additional assessments are necessary to pinpoint whether all relevant prerequisite skills have been mastered. Finally, using evaluation as the central focus seems most appropriate for the field of applied behavior analysis with its emphasis on applying the science of behavior to socially significant behaviors. The goal is not just to analyze behavior and change it but rather to analyze behaviors that are socially important and then change them in ways that are socially acceptable and meaningful.

The purpose of this article is to provide a practical framework for the planning and development of comprehensive programming. Although we believe the framework is applicable for a wide variety of populations receiving comprehensive programming, the authors, based on their experience, will focus on programming examples for individuals with autism. The suggestions are meant to be a starting point for how to create more robust treatment. They are not meant to be exhaustive but rather present what the authors propose, based on their experience over the past 2 decades creating comprehensive programming, as significant actions for improving treatment. This article will review each component of the ADDIE instructional design model, identify three recommended actions that behavioral practitioners might take to improve their practice within each component (see Figure 2), and provide resources to help in taking those actions (see Table 1).

Fig. 2.

Key Actions in the Development of Comprehensive Programming

Table 1.

Resources to Help with Key Actions

Analyze
Key Action		Specific Actions for Improvement	Resources
Identify the purpose of the assessment.		□ I know why I am using the assessment I have chosen. I consider the following elements when choosing an assessment:	BHCOE ABA Outcomes Framework https://www.bhcoe.org/project/bhcoe-aba-outcomes-framework/
		□ comprehensiveness	Gould et al. (2011)
		□ developmental level □ functions of behavior
		□ technical adequacy □ family concerns and priorities □ developmental vs functional skills	Cicchetti (1994), Sullivan (2011) Shepley & Grisham-Brown (2019) McGreevy & Fry (2021)
Complete a training on more than one available assessment for Comprehensive ABA Treatment.		□ I am familiar with the variety of assessments available.	Gould et al. (2011)
		□ I have trained on a variety of assessment instruments.	BHCOE ABA Assessment Workshop https://learning.bhcoe.org/collections/aba-assessment-workshop-bundle
		□ I have found a colleague who is already familiar with an assessment to help me with it.
		I have taken a training on the following assessments:
		□ PEAK □ VB-MAPP □ ABLLS-R □ EFL	https://www.peak2aba.com/ https://training.vbmappapp.com/ https://training.webablls.net/ http://essentialforliving.com/training/
Use secondary assessments to fill in the gaps of a primary assessment.		I have used the following as secondary assessments: □ norm-referenced assessments □ criterion-referenced assessments □ assessments found in journals □ assessments from a book □ self-made assessments
Design
Key Action		Specific Actions for Improvement	Resources
Identify ABA program manuals that are available		□ I am familiar with comprehensive program manuals.	Najdowski et al. (2014)
		□ I am familiar with skill specific program manuals.	Champlin & Schissler (2017) Frost & Bondy (2002) https://pecsusa.com/training-series/ Najdowski (2017) Weiss & Harris (2001)
Identify the order of skill development that will work best.		□ I am familiar with the order of developmental milestones for my clients.	Centers for Disease Control & Prevention (2022) Johnson-Martin et al. (1990) Sax & Weston (2007)
		□ I am familiar with prerequisite skills for the skills I want to teach.	Aguirre & Gutierrez (2019) Contreras et al. (2020) Kodak et al. (2015)
		□ I have determined whether the skills I am interested in teaching are component skills or composite skills.	Spencer (2021)
		□ Rather than fill in the next bubble on an assessment, I have determined which skills should be taught and which skills should develop on their own.	Gibbs & Tullis (2021) Hixson (2004)
Determine when a target and a program will be considered complete.		□ I am familiar with different approaches to multiple exemplar training.	Schnell et al. (2018)
		□ I am familiar with the seven steps to broaden the scope of a skill.	Johnson & Bulla (2021)
		□ I have determined if this target/skill will be used in other programs, immediately generalized in the natural environment, or need to be maintained for longer periods of time. □ I have determined if this program should focus on the specific number of targets, generalized responding, or something else.	McDougale et al. (2020)
Develop
Key Action	Specific Actions for Improvement		Resources
Compare teaching formats to identify the one that will work best.	I am familiar with a wide variety of teaching formats to include:
	□ Discrete Trial Teaching □ Progressive ABA □ Embedded Discrete Trial Teaching □ Naturalistic Developmental Behavioral Interventions		Eikeseth et al. (2014) Leaf, Cihon et al. (2016) https://progressivebehavioranalyst.org/ Haq & Aranki (2019) Frost et al. (2020) Schreibman et al. (2015)
Use different materials to identify those most efficient for the client’s learning.	I have probed the following materials to determine which type may be best to initially teach a skill: □ objects □ pictures □ people □ person □ pixels
	□ I have considered both acquisition rate and client preference when choosing one of the above materials.		Carroll et al. (2018) Markham et al. (2020)
Compare teaching procedures to identify the one that will work best.	□ I am familiar with the list of 28 evidence-based procedures compiled through a systematic review of the research.		Hume et al. (2021)
	□ I have searched for journal articles comparing different procedural variations with the ones I am familiar.		Bottini et al. (2018) Cengher et al. (2018) Leon et al. (2021) Schnell et al. (2020) Weinsztok et al. (2022)
	□ I am familiar with the components of assessment-based instruction to help determine which teaching procedure works best for a client.		Kodak & Halbur (2021)
Implement
Key Action		Specific Actions for Improvement	Resources
Provide training to ensure correct implementation of the treatment		□ I am competent in behavioral skills training.	Sarokoff & Sturmey (2004) Slane & Lieberman‐Betz (2021)
Advocate for a standard of oversight that ensures treatment fidelity and progress		I have joined and am active in one of the following organizations: □ APBA □ BHCOE □ CASP □ ACQ	https://www.apbahome.net/ https://www.bhcoe.org/ https://casproviders.org/ https://casproviders.org/the-autism-commission-on-quality/
Problem solve difficulties in skill acquisition or behavior reduction.		□ I can systematically assess when problems arise in discrete trial teaching.	Ferraioli et al. (2005)
		□ I have taught technicians to make in-the-moment decisions.	Leaf, Leaf et al. (2016a, 2016b)
		□ I have used the Performance Diagnostic Checklist – Human Services (PDC-HS) to identify the best way to improve technician performance.	Carr et al. (2013) Wilder et al. (2018)
Evaluate
Key Action		Specific Actions for Improvement	Resources
Confirm that the goals are socially valid.		□ I have discussed with the parents to confirm the importance of this skill.
		I am familiar with techniques that promote dialogue from: □ motivational interviewing □ acceptance and commitment therapy □ compassionate care	Bricker & Tollison (2011) Tarbox et al. (2022) Taylor et al. (2019)
		□ I practice cultural humility in my interactions with parents. □ I have considered the perspectives of both society and the individual when it comes to goals.	Beaulieu & Jimenez-Gomez (2022)
Confirm that the procedures are socially valid.		□ I am familiar with the criticisms of ABA from some in the neurodivergent community.	Leaf et al. (2022)
		□ I ensure that parents are truly informed before giving consent to the procedures I wish to use.	Glaser et al. (2020)
		□ I include client assent for the procedures I wish to use.	Breaux & Smith (2023) Flowers & Dawes (2023) Morris et al. (2021)
Confirm that the outcomes are socially valid		□ I track outcome data for the individuals to whom I provide services.	Grzadzinski (2020) Smith et al. (2021)
		□ I am familiar with the objective measures of quality of life.	Hong et al. (2016)
		□ I have considered the perspectives of both society and the individual when it comes to outcome.	Taylor (2017) Veneziano & Shea (2022)

 If you have already completed a specific action, shade in that box. Put a + in the box by the specific action(s) you wish to accomplish next. Additional boxes have been included for you to write in any of your own ideas of specific actions in that area.

Analyze

The analysis component of ADDIE focuses on gathering data to assess what needs to be taught. The number and variety of assessments in the field of behavior analysis continue to increase. In addition, assessments continue to evolve as practitioners identify new ways to break down complex skills, researchers determine the validity of each assessment, and the community reevaluates which skills are most important. Recommended actions that behavioral practitioners might take include the following:

Action 1: Identify the Purpose of the Assessment

One criticism of ABA treatment is the potential for behavioral practitioners to implement rigid, formulaic treatment (Devita-Raeburn, 2016). Leaf et al. (2021) provide context to this criticism by discriminating between the competence of different behavioral practitioners and the types of repertoires that aid in flexible, dynamic treatment. One skill behavioral practitioners might do well to develop is the ability to constantly ask why they are doing what they are doing. What is the rationale behind this procedure, this program, or this target? Why choose to use this assessment?

Gould et al. (2011) suggest five critical components when choosing an assessment for early intensive behavioral intervention, a common form of Comprehensive ABA Treatment. They looked for assessments that were comprehensive, focused on early childhood development, considered behavior function, included enough precision to link assessment items to behavioral targets, and allowed tracking of progress over time. Shepley and Grisham-Brown (2019) strongly recommend that behavioral practitioners become more familiar with an assessment’s technical adequacy (the validity, reliability, and bias of an assessment) when choosing an assessment for program planning. For those not already aware of the various factors that go into the development of a valid and reliable assessment, Cicchetti (1994) and Sullivan (2011) are two resources that concisely discuss these factors and the limitations of assessments that are still in development. Shepley and Grisham-Brown (2019) also note that program planning assessment is more than just assessing the skill level of a client. Assessment might also include collecting information on a family’s concerns and priorities as well as the interests and preferences of the client. Finally, McGreevy and Fry (2021) distinguish between assessments for clients whose comprehensive treatment may focus on acquiring developmental skills in line with typically developing peers and assessments for clients whose comprehensive treatment may focus on acquiring functional skills in line with an increased quality of life. Behavioral practitioners who reflect on the purpose behind the assessment they are choosing and consider the above factors when choosing an assessment are much more likely to acquire the important information necessary to create robust Comprehensive ABA Treatment that aligns with a specific client’s needs.

Action 2: Complete a Training on More than One Available Assessment for Comprehensive ABA Treatment

Because of the ongoing introduction of new assessments in behavioral treatment, behavioral practitioners might consider remaining aware of what is available. Gould et al. (2011) review 27 available assessments that help in programming comprehensive treatment. Those assessments were selected from a larger list compiled by Luiselli et al. (2001). Padilla (2020) provides insights into current assessment practices of behavior analysts and identifies some of the most frequently used comprehensive assessments, including the Verbal Behavior Milestones Assessment and Placement Program (VB-MAPP), Assessment of Basic Language and Learning Skills, Revised (ABLLS-R), Vineland Adaptive Behavior Scales (VABS), and Promoting the Emergence of Advanced Knowledge Relational Training System (PEAK).

Many comprehensive assessments now offer virtual training. As an alternative, one might work collaboratively with a colleague who is already familiar with an assessment. The goal of this action is to increase one’s scope of competence in assessments (Brodhead, 2018). By becoming competent with a variety of assessments, behavioral practitioners increase their knowledge of skills and skill progression that may be worth including in Comprehensive ABA Treatment for a particular client.

Action 3: Use Secondary Assessments to Fill in the Gaps of a Primary Assessment

In order to gain enough information, behavioral practitioners may call upon norm-referenced assessments, criterion-referenced assessments, assessments published in journals, assessments published in books, and those developed by the behavior analysts themselves. Behavioral practitioners often have a few assessments that they typically use in their practice. Using additional assessments can make a behavioral practitioner’s Comprehensive ABA Treatment more robust either by focusing on a different assessment goal or by filling in the gaps that the primary assessment misses.

Much has been written about the need for behavioral assessments to undergo rigorous tests for reliability and validity (Padilla & Akers, 2021; Shepley & Grisham-Brown, 2019) and progress continues to be made in this endeavor (Belisle, Dixon, Malkin et al., 2022a, 2022b; Belisle, Dixon, Munoz et al., 2022a, 2022b; Malkin et al., 2017; May & Flake, 2019; Padilla & Akers, 2021; Usry et al., 2018). Behavioral practitioners who are familiar with criterion-based assessments like the VB-MAPP, PEAK, and ABLLS-R may want to also include a norm-referenced assessment, such as the Vineland Adaptive Behavior Scales or Pervasive Developmental Disorder Behavior Inventory, in order to evaluate the effects of comprehensive treatment for one client compared to the progress of many other individuals.

The advantage of many criterion-referenced assessments in ABA is the degree to which they break down skills into manageable behaviors to teach. Still, no assessment covers everything for every client. Behavioral practitioners who branch out from using one assessment may find that other available resources can fill in the gaps or provide alternative paths for skill development. For example, the Early Start Denver Model Curriculum Assessment for Young Children with Autism (2009) provides an assessment for toddlers broken into four levels, with the first level including nearly 100 skills in 13 domains that are relevant to children as young as 12 months. For clients who need additional help with play skills, the Pretend Play and Language Assessment and Curriculum (2017) is a recent addition that provides a finely detailed, systematic approach to assessing play skills. For clients who struggle with learning conversation skills, journal articles provide assessment guidance for skills to increase (Bauminger et al., 2017), skills to decrease (Bauminger et al., 2013), and the context within which different conversation skills are useful (Hood et al., 2017). Behavioral practitioners who identify and use secondary assessments as well as a primary assessment can both expand the directions in which they may take treatment and gain insights into the relevance of the skills they are targeting.

Design

The design component of ADDIE creates a basic blueprint to follow in order to systematically teach new skills. Behavioral practitioners may want to consider multiple ABA programming manuals, prerequisite skills that are needed prior to teaching a new behavior, and coordinating the acquisition of new skills toward a final purpose. Recommended actions that behavioral practitioners might take during the design phase include the following:

Action 1: Identify ABA Program Manuals that Are Available as a Starting Point

Similar to assessments, the number of comprehensive curricula available to professionals serving clients has increased substantially over the years. The Lovaas (1981) manual, referred to as The Me-Book, was the first and only available published behavioral curriculum for young children with autism for over a decade. In the mid-1990s, a second manual became available from Maurice (1996) entitled Behavioral Interventions for Young Children with Autism, followed a few years later by the Leaf and McEachin (1999) contribution, A Work in Progress. Beyond comprehensive curricula, there are also now resources available for specific skill areas. Weiss and Harris (2001) published Reaching Out, Joining In: Teaching Social Skills to Young Children with Autism in order to provide more direction for developing social skills such as conversation. Najdowski (2017) wrote Flexible and Focused: Teaching Executive Function Skills to Individuals with Autism and Attention Disorders as a resource for those working on complex planning and self-management skills. In fact, a quick search on Amazon of “ABA curriculum for autism” will now produce over 100 results.

Najdowski et al. (2014) reviewed 22 curricula that are commercially available and widely utilized for comprehensive behavioral treatment. The article evaluates the curricula on a variety of factors, including skills domains, age range, measurement, and tracking features. Behavioral practitioners who are familiar with a variety of program manuals can strengthen their programming abilities not only because they will be familiar with more program options, but also because most program manuals also provide a general structure for how to systematically introduce those programs.

Action 2: Identify the Order of Skill Development that Will Work Best

Behavioral practitioners might combine the programs they gather into an overall sequence. Sequence refers to the necessary versus optional order in which skills are taught. It must be admitted that behavioral practitioners often rely on clinical judgment when making these decisions. A few insights in this area are worth mentioning.

First, one misstep behavioral practitioners might avoid is to simply create programs based on the next skill that needs completed on an assessment. Comprehensive programming requires a behavioral practitioner to link programs together across domains. Some skills rely on first acquiring other skills in other domains. For example, the Assessment of Basic Learning Abilities (Kerr et al., 1977; Kodak et al., 2015) identified skills in the area of imitation and matching that lead to success in receptive language skills. Some curriculum resources such as Behavioral Interventions for Young Children with Autism and A Work in Progress already provide a basic sequence to help behavioral practitioners identify prerequisite skills that are needed before introducing a program. An additional reference for determining sequence is the order in which skills develop for typically developing children. The Carolina Curriculum for Preschoolers with Special Needs by Johnson-Martin et al. (1990) is one available resource that identifies specific skills to teach and sequences them by the developmental milestones of typically developing children. In addition, the Centers for Disease Control and Prevention (2022) has created downloadable milestones checklists ranging from 2 months to 5 years. Developmental checklists that focus more specifically on language, such as Sax and Weston (2007), are also readily available on the internet. Meanwhile, published research also provides insights into efficient skill sequencing that can inform treatment. As one example, Aguirre and Gutierrez (2019) research and discuss the development of imitation skills for both autistic children and neurotypical children. They note a general hierarchy of skill development, starting with object imitation and then moving to body imitation, vocal imitation, and facial imitation. They also discuss the relevance of additional features, such as meaningful versus nonmeaningful imitations, imitations with or without sounds, and the degree to which imitations are visible to the person performing the action. As another example, the interrelation between early tact and listener responding skills is an area of skill sequencing that has been studied by multiple authors and compiled in two articles (Contreras et al., 2020; Petursdottir & Carr, 2011). They note that the basic recommendation to teach listener skills before teaching speaker skills is not so clearly supported by the research.

Second, behavioral practitioners might consider what basic skills (component skills) are needed in order to acquire a more complex skill (composite skill). The identification of component versus composite skills is probably best described in the Direct Instruction literature. Spencer (2021) suggests steps for instructional design through the lens of Direct Instruction and discusses how basic skills and component skills are nested inside composite skills.

Finally, when considering sequence, behavioral practitioners can also focus on which skills are necessary components of other skills (and therefore should be taught first), which skills are related but not consecutive (and so other factors can determine the order to teach) and which skills are likely to develop on their own once other skills are taught (and therefore should not be taught at all). For example, the VB-MAPP assesses whether a client can imitate 20 fine motor actions, but that does not mean one must create a program that focuses on imitating 20 specific fine motor actions. The goal of early imitation is generalized responding, in which a client will attempt to imitate any action. In addition, fine motor skills are a continually developing skill for young children. Therefore, it may be better when creating a program sequence to focus on only a few fine motor imitations before moving on to other fine motor games and activities to build up a client’s fine motor repertoire. Rather than solely focusing on 20 fine motor imitations, using a combination of generalized imitation responding and improvement in fine motor skills might lead to a client who later naturally imitates more than 20 fine motor actions. Behavioral practitioners who want to have a better understanding of which skills may not need to be directly targeted can look to research in behavioral cusps (Bosch & Fuqua, 2001; Hixson, 2004; Rosales‐Ruiz & Baer, 1997) and emergent learning (Bejnö et al., 2018; Critchfield, 2018; Gibbs & Tullis, 2021).

Action 3: Determine When a Target and a Program Will be Considered Complete

Scope refers to how widely or deeply to develop a skill. Behavioral practitioners might balance focusing on a skill broadly enough to make that one skill useful in any situation while at the same time ensuring that enough skills are taught to make the right skills available in the right situations. Within a program, behavioral practitioners make several decisions about what it means for a specific target to be mastered. Note that the term “mastery” has no more meaning beyond that assigned by the behavioral practitioner. One determination of mastery is the extent to which a skill is generalized across people, settings, or materials. One behavioral practitioner may create a program in which a single exemplar is mastered and future programs then focus on additional exemplars. For example, a client may learn to tact one picture of a horse, one picture of a tree, one picture of a car, and then focus on additional exemplars of each picture only after learning a predetermined number of 10 tacts. Another behavioral practitioner may create a program that randomly shows one of five different pictures of a horse. The target of tacting a horse is not considered mastered until the client can tact all the pictures of the horse. Yet another behavioral practitioner may create a program in which a client learns to tact pictures of a horse, but the target is not considered mastered until the client is able to tact “horse” to a novel horse picture. Recent work on multiple exemplar teaching (Schnell et al., 2018) demonstrates that different approaches may be beneficial for different clients. Johnson and Bulla (2021) also provide a careful analysis of seven steps to broaden the scope of a skill beyond multiple exemplar teaching.

Another determination of mastery that has received recent attention is how consistently a client must respond correctly in order to master a target. Fuller and Fienup (2018) studied the effects of 50%, 80%, and 100% mastery criterion and found that higher mastery criterion resulted in higher correct responding during maintenance trials. Richling et al. (2019) conducted a survey and found that 80% success across three consecutive sessions was the most common practice by behavioral practitioners. Meanwhile, McDougale et al. (2020) discuss mastery criteria in practice compared to mastery criteria used in the research and discuss potential reasons for the differences between the two. One reason for the discrepancy not discussed in the article may be that behavioral practitioners are not as concerned about maintenance of a skill because they intend for the mastered target or skill to continue to be practiced daily or every few days, either in the natural environment or within the context of other ongoing programming. Still, when determining the scope of programming, behavioral practitioners might consider whether maintenance of a skill for long periods of time is a necessary part of target mastery and whether to set a higher or lower accuracy criterion for mastery.

Besides determining when a specific target is considered mastered, behavioral practitioners also determine when a program is complete. As part of this decision, behavioral practitioners decide whether specific targets or an overall skill are of more importance. For example, a behavioral practitioner may develop a safety program whose purpose is to teach a client to identify his name, phone number, and address. In this case, the client’s ability to respond to those three targets is the focus of the program. The behavioral practitioner may identify the completion of that program as when the client can respond correctly to those questions from a variety of people in a variety of contexts and when much time has passed since the questions were last asked. As another example, a behavioral practitioner may develop an imitation program whose purpose is to teach a client to imitate any gross motor movement. The program is only considered complete when the client will immediately imitate, or at least attempt to imitate, novel gross motor actions. As a final example, a behavioral practitioner may develop a tact program whose purpose is to decrease the length of time it takes for a client to learn a new word. One hallmark of language development in typically developing children is learning and using new words quickly. A tact program may not be finished just because a client learns 50 new words. At the same time, we would not expect a client to immediately use a new word they have never encountered before. Instead, the tact program may be considered complete when a client can tact new words after only a few exposures to the word (Olaff & Holth, 2017).

In the end, one of two outcomes is often appropriate when determining the scope of a program. Some skills might be practiced until they are used in the natural environment frequently enough for natural reinforcers to maintain them. Requesting skills frequently fall within this category. Once a client learns to request something they like, the skill is often expected to maintain in the home environment through frequent use. Whether it is maintained may also depend on how easily the skill is generalized in the home environment with caregivers (Carruthers et al., 2020), but the point is that the completion of a program is determined by its use within the natural environment. On the other hand, some skills might be practiced until they can be used in other, more complex programs. A program that focuses on one component skill may then be integrated into another program that focuses on a composite skill made up of component skills. For example, after learning to match two identical pictures, clients may go on to match nonidentical pictures, sort objects into piles, or put dishes away in the same spot as similar dishes. Each of these skills would maintain aspects of the original picture-to-picture matching program and may make maintaining the original program irrelevant.

Develop

The development phase further embellishes the blueprint of programming created in the design phase. Focusing on the nuts and bolts of programming might include efforts to individualize both the teaching procedures and the overall teaching format. Recommended actions that behavioral practitioners might take during the development phase include the following:

Action 1: Compare Teaching Formats to Identify the One that Will Work Best.

Research and practice over the course of the past 5 decades have led to the development of many promising teaching formats. The formats are not mutually exclusive but rather emphasize different evidence-based factors that affect learning. Discrete Trial Teaching (Eikeseth et al., 2014) focuses on a careful analysis of the immediate antecedent-behavior-consequence sequence that affects learning. At its core, a discrete trial is a five-part teaching sequence composed of a cue, prompt, response, consequence, and intertrial interval (Smith, 2001). Each element of discrete trial teaching can vary based on what works best for a particular client. Cues can include more or less words (Green, 2001; Leaf, Cihon et al., 2016). A variety of different prompts can be used (Cengher et al., 2020). Response variability can be included (de Matos et al., 2021). Consequences can come from a variety of reinforcers (Weinsztok et al, 2023). And, the intertrial interval can vary in length (Cariveau et al., 2016). Progressive ABA is a recent reflection on the teaching formats available to behavioral practitioners and encourages a dynamic approach to ABA. Progressive ABA is a teaching format that emphasizes the importance of in-the-moment decision making and clinical judgment to affect the way in which discrete trials are conducted (Leaf, Leaf et al., 2016a, 2016b). It includes basic guidelines, such as using flexible prompting, varying instructions as soon as possible, and teaching additional skills with instructive feedback (Leaf, Cihon et al., 2016). Furthermore, Embedded Discrete Trial Teaching is another recent format that emphasizes the use of games and activities the client enjoys as the consequence for correct responding (Geiger et al., 2012; Haq & Aranki, 2019). The emphasis on creative and more natural types of reinforcers is encouraging, but one might also remember that there is nothing magical in the game itself. Games serve as important forms of motivating operations and reinforcement but need to continue to be assessed as such so that a client does not satiate on the game. Finally, a wealth of teaching formats also falls into the category of Naturalistic Developmental Behavioral Interventions (NDBI), such as incidental teaching, pivotal response training, enhanced milieu teaching, and reciprocal imitation training (Frost et al., 2020; Schreibman et al., 2015; Schuck et al., 2022). These teaching formats include natural reinforcement within the context of social routines. They remind the behavioral practitioner to consider the continuum of contrived to naturalistic formats and structured to unstructured formats available to them.

Action 2: Use Different Materials to Identify Those Most Efficient for the Client’s Learning

Behavioral practitioners might consider at least five different modes of stimuli when teaching skills. Peterson et al. (2003) identify objects, pictures, person (the client), and people (the therapist and others) as different modes of stimuli for training and generalization. Pixels, or video, is a fifth mode of stimuli that may be considered in both teaching and generalization (MacManus et al., 2015). Not all modes of stimuli will apply in every circumstance, and some may not be worth teaching. However, reflecting on the best stimuli to use, based on client preference and acquisition rate, may be a useful way to turn a good program into a great program. Consider a basic Identifying Actions program and the stimuli that could be used within that program. Suppose the goal is for the client to tact the action taking place in the moment (e.g., “eating pizza”). A common way to conduct this program is with pictures. The technician shows the client a picture of a person eating pizza and asks, “What’s happening?” However, each of the other four modes of stimuli are also ways to initially introduce tacting actions. First, other people like the technician could show the action. The technician might take a pretend piece of pizza, pretend to eat it, and ask, “What’s happening?” Second, the client could perform the action. The technician might wait for the client to eat lunch or have the client imitate the technician’s pretending to eat and then immediately ask, “What are you doing?” Third, other objects could be used to show the action. For example, the client’s favorite stuffed animal or character could be used in play. The technician could have the stuffed animal pretend to eat a piece of pizza and ask, “What’s the doggy doing?” Finally, the technician could show the client a video of someone eating pizza, pause the video, and ask what that person is doing. Considering the use of objects, pictures, people, person, and pixels as modes of stimuli may reveal new program formats. Such program formats can lead to more dynamic and creative programming. Clients could learn prepositions by standing on top of and going under tables, chairs, and bean bags. Clients could learn to describe emotions after watching those emotions on YouTube. Clients could learn to identify foods while playing with a kitchen set. Which mode of stimuli to teach first—object, pictures, people, person, or pixels—may be determined by a variety of factors. For example, a client can continue to look at a picture of a person eating a pizza, which may help when initially learning to tact. However, the action in the picture is static, which may cause difficulty identifying actions like jumping or throwing. As an alternative, a video of a person jumping shows the action in motion, but it may be more difficult to set up the program efficiently so that actions are practiced frequently. Finally, focusing on actions performed by the client or technician may more quickly generalize to real world situations, but the actions do not always remain visible when the client is asked what just happened. Factors to consider include the preference of the client, the complexity of the format, the likelihood of generalization, and the insights from research. Behavioral practitioners might even consider using a rapid assessment (Carroll et al., 2018; Lerman et al., 2004) or concurrent-chains preference assessment (Basile et al., 2021; Markham et al., 2020) to determine which stimuli to use. At the very least, when behavioral practitioners use and take note of acquisition rate for different modes of stimuli throughout Comprehensive ABA Treatment, they can learn which materials result in the most efficient learning for an individual client.

Action 3: Compare Teaching Procedures to Identify the One that Will Work Best

Hume et al. (2021) identified a list of 28 different, evidence-based procedures, almost all of which are used within the field of applied behavior analysis. In addition, decisions such as the types of prompts to use (Cengher et al., 2018; Schnell et al., 2020), whether to intermix different types of mastered and acquired targets (Bottini et al., 2018), the order of stimulus presentation (Bergmann et al., 2021; Leon et al., 2021; Schneider et al., 2018), and the parameters of reinforcement delivery (Weinsztok et al., 2022) are just a few examples of decisions that may affect how quickly a skill is mastered. A recent article by Kodak and Halbur (2021) provides a useful tutorial for comparing teaching strategies. Behavioral practitioners can also improve their programming by remaining familiar with the advances in these procedures and the wide variety of decisions available within each procedure. A fruitful starting point is a Google Scholar search that includes the terms: “comparison” + “applied behavior analysis” + procedure or method for review, such as “prompt” + operant or domain, such as “tact.” Most research, of course, should still be considered preliminary in that a comparison study will often only include a few participants from a specific demographic with only an occasional replication article.

Comprehensive ABA Treatment will always begin with behavioral practitioners’ using the knowledge and experience from their past to develop a program. A behavioral practitioner’s ability to humbly assess why they do what they do is an important tool for finding effective and efficient teaching procedures for a client. Are teaching procedures chosen because that is what the behavioral practitioner has always done, because of one recent article they have read, or because the practitioner has carefully considered a variety of procedures and has then determined to start with a specific one based on rationale for a particular client.

Implement

The implementation phase of the ADDIE model is different for Comprehensive ABA Treatment compared to its use in the educational field. In education, teachers typically develop and implement the curriculum. In Comprehensive ABA Treatment, behavioral practitioners develop the curriculum whereas behavioral technicians implement the curriculum. This delegation of responsibility to technicians drives critical actions that behavioral practitioners might take during the implementation phase. Recommended actions that behavioral practitioners might take include the following:

Action 1: Provide Training to Ensure Correct Implementation of the Treatment

Knowing what to do and doing it are two separate things. Behavioral skills training (BST) is well-suited to address the need for technicians to not only know what to do but to also actually do it. Behavioral practitioners who are familiar with the four basic steps of BST—instruction, modeling, rehearsal, and feedback (Sarokoff & Sturmey, 2004)—are at an advantage for ensuring the program they have put together is implemented correctly (Clayton & Headley, 2019; Dart et al., 2017; Jimenez‐Gomez, 2019; Slane & Lieberman‐Betz, 2021). Other factors that may determine the amount of training include the complexity of the task and prior experience of the technician. In the end, behavioral practitioners focus on training that continues until technicians demonstrate competency (Brand et al., 2017; Brand et al., 2018; Cook et al., 2015).

Action 2: Advocate for a Standard of Oversight that Ensures Treatment Fidelity and Progress

Based on scientific evidence and after careful deliberation and consensus from subject matter experts, the Behavior Analyst Certification Board (2012) summarized practice guidelines for the use of applied behavior analysis in treating individuals with autism. Now maintained by the Council of Autism Service Providers (2020), the guidelines include a general standard of care regarding oversight of ABA services by behavioral practitioners. Those guidelines state that Comprehensive ABA Treatment requires clinical direction in the range of 10%–20% of the total hours of treatment from a behavioral practitioner while the client is present. In other words, a client receiving 40 hr of treatment per week requires 4–8 hr of oversight per week from a behavioral practitioner. This established standard of care makes sense when one considers all the factors that affect most ABA programming, including all the variations of programming that are possible, the comprehensive nature of the program itself, the ongoing modifications that are necessary for different clients to make progress, the inexperience of many technicians, and the high turnover rate of technicians. In fact, many of the recommended actions in this article may not be practically feasible without such a level of oversight. Behavioral practitioners might continue to demand that they are given the time needed to ensure treatment fidelity, including observing therapy with the client and then problem-solving difficulties away from the client. This push might be directed at both providers and funders. One might search for providers that assign a caseload in which 4–8 hr of oversight is possible. In addition, one might advocate for appropriate reimbursement for the business so that this level of oversight can take place. Joining organizations like the Association for Professional Behavior Analysts (APBA) and The Council of Autism Service Providers (CASP) or participating in the work of organizations like Behavioral Health Center of Excellence (BHCOE) and the Autism Commission on Quality (ACQ) are ways to support those whose mission is to promote provider best practices. The importance of quality oversight has already been identified in the research as a critical factor in overall progress (Dixon et al., 2016; Eikeseth et al., 2009; Långh et al, 2022). The more customization one does for protocols, the more oversight is needed. Ensuring a behavioral practitioner can provide that oversight is critical to the success of Comprehensive ABA Treatment.

Action 3: Problem Solve Difficulties in Skill Acquisition or Behavior Reduction

Difficulties in skill acquisition may arise from a skill deficit so that additional prerequisites need to be taught, motivational deficits which require contingency modifications, or staff training concerns. Ferraioli et al. (2005) provides a wealth of flowcharts for identifying problems and considering solutions during treatment, specifically for Discrete Trial Teaching. The problems and solutions are applicable to a variety of different teaching formats and procedures in ABA. The article recommends that behavioral practitioners expect progress to occur within 8–10 teaching sessions and review treatment frequently enough to meet that expectation. Further, Progressive ABA places an emphasis on behavioral practitioners who teach technicians to use in-the-moment clinical judgment in areas such as prompting, reinforcer choice, and basic functional assessment (Leaf, Cihon et al., 2016; Leaf, Leaf et al., 2016a, 2016b) to overcome problems, keep a client successful, and increase acquisition rate.

The Performance Diagnostic Checklist-Human Services (PDC-HS) is another problem-solving tool that can help behavioral practitioners refine errors in teaching (Carr et al., 2013; Wilder et al., 2018) The PDC-HS evaluates potential employee performance issues and provides recommendations based on behavioral principles. The tool assesses performance based on four environmental factors: (1) training; (2) task clarification and prompting; (3) resources, materials, and processes; and (4) performance consequences, effort, and competition. The evaluation contributes to best practices in implementation by treating the environment as the problem rather than the person.

Evaluate

Within the ADDIE framework used in this article, evaluation lies at the center. Evaluation is not just about checking whether something is taught and learned. It is also about asking whether a skill was taught well and why it was even important to teach in the first place. Evaluation may focus on the social validity of what is taught, how it is taught, and the outcomes that result. Evaluation is about reflection, and authentic reflection affects all the other elements of the ADDIE process. Recommended actions that behavioral practitioners might take in the evaluation phase include the following:

Action 1: Confirm That the Goals are Socially Valid

Behavioral practitioners might make sure the skills they are assessing and teaching are the ones that are most important to teach. In essence, behavioral practitioners might ask what is the overall purpose of the skill for this client and whether it truly matters. As a question of values, input from caregivers and the client become an important part of answering that question. Preliminary evidence suggests that behavioral practitioners can increase successful dialogue with caregivers through familiarity with techniques from motivational interviewing (Christopher & Dougher, 2009; Fenning & Butter, 2019), acceptance and commitment therapy (Bricker & Tollison, 2011; Byrne et al., 2021; Tarbox et al., 2022), and compassionate care (LeBlanc, Sellers et al., 2020; Taylor et al., 2019). When talking with caregivers, behavioral practitioners might also be sensitive to the cultural diversity of the client’s environment (Beaulieu et al., 2019; Fong et al., 2016). It is all too easy to assume the client’s or family’s life experiences are similar to one’s own life experiences. Instead, behavioral practitioners might recognize that some aspects of cultural identity that are unfamiliar or unimportant to the practitioner, such as race, gender, religion, or socioeconomic status, may be important to other people. (Foronda et al., 2016; Ortega & Faller, 2011; Tervalon & Murray-Garcia, 1998). In order to assist behavioral practitioners in developing cultural humility, Fong and Tanaka (2013) provide a list of seven actions to promote cultural competence. Likewise, Beaulieu and Jimenez-Gomez (2022) provide a list of 25 actions to promote culturally responsive practices. Such resources can prepare behavioral practitioners to truly assess with a family whether the goals of treatment are valuable to the family and to the client. Recognizing the complexity and uniqueness of everyone’s environment, actively and reflectively listening to caregiver input, and starting from a nonjudgmental framework that is open to differences in perspective may help behavioral practitioners focus treatment on the particular situation of the client in this family within this community.

Action 2: Confirm That the Procedures are Socially Valid

Just because we can teach in a certain way does not mean we should teach in that way. Society is continually assessing what is acceptable and not acceptable when it comes to the way we treat others. For instance, in the 1960s, cigarette smoking was an acceptable activity for adults, and behavioral treatment included it in some forms of treatment (Ayllon & Haughton, 1964; Kale et al., 1968). In the 1970s and early 1980s, most school districts continued to include corporal punishment as a valid form of discipline (Gershoff & Font, 2016; Holden et al., 2018), and ABA treatment employed similar strategies (Leaf et al., 2022). Today, some autistic adults, family members, and behavioral practitioners in the field continue to push back against other procedures that are currently considered acceptable, such as physical prompting and escape extinction (Cernius, 2020; Ram, 2020). Behavioral practitioners might embrace this never-ending process of considering what they do, being open to hearing alternative voices, and adjusting treatment procedures accordingly (Leaf et al., 2021; Rajaraman et al., 2022).

In addition, behavioral practitioners might consider how they go about obtaining informed consent. To what extent are caregivers aware of the procedures that a behavioral practitioner plans to implement with their client? Has the behavioral practitioner explained the risks and benefits? Have they offered alternatives and explained those risks and benefits? Have caregivers only received written information on the procedure, do they have access to more information and videos on the internet, or better yet have the caregivers seen the procedure in action with their client (Glaser et al., 2020) and are they both willing and able to implement similar procedures at home? Some behavior practitioners promote the importance of the televisibility of ABA treatment (Hanley, 2020). They believe ABA therapy should be something that we are more than willing to have videotaped and shared with the world. Such a mantra serves behavioral practitioners well when initially considering whether treatment procedures are socially valid.

Finally, the significance of obtaining client assent throughout behavioral treatment is an emerging area of discussion that behavioral practitioners would do well to consider (Breaux & Smith, 2023; Flowers & Dawes, 2023; Morris et al., 2021). Beyond vocal approval, behavioral practitioners can use a concurrent chains procedure, other variations of choice, and even facial expressions or body movements to determine if a client provides assent. In addition, behavioral practitioners need to determine what to do if a client does not assent to treatment and the ethical implications of those decisions.

Action 3: Confirm That the Outcomes are Socially Valid

Just because something looks good in treatment does not mean it results in a benefit for the individual later in life. Behavioral practitioners might continue to track and confirm that treatment results in meaningful outcomes (Dimian et al., 2022; Grzadzinski et al., 2020; Smith et al., 2021). This data collection first starts with ongoing communication with caregivers. To what extent do caregivers see changes at home based on what is happening in therapy? If caregivers do not notice much change, there are a variety of follow-up questions. Do the caregivers need additional training in treatment procedures to increase the likelihood they will see changes at home? Does the client need a greater level of mastery and generalization in therapy prior to expecting changes at home? Does a greater discussion need to occur about what caregivers want to see change at home prior to deciding what programs to implement in therapy? Even then, outcome is more than just generalization to the home. Behavioral practitioners need to know how treatment affects later freedom and quality of life for the individual who was treated. (Bal et al., 2018; Bishop-Fitzpatrick, 2016; Hong et al., 2016). This question can be answered from the perspective of society (e.g., that person is now able to receive an education with less support, hold a job, live on their own). The question might also be answered from the perspective of the individual (Taylor, 2017, Veneziano & Shea, 2022). For example, a person may be happy with few social interactions because they like to spend time playing video games. Comprehensive ABA Treatment is not successful simply because a behavioral practitioner is able to check off all the boxes of an assessment. Rather, Comprehensive ABA Treatment is successful when a behavioral practitioner can confirm the individual’s quality of life has improved in areas such as: interpersonal relations, social inclusion, personal development, physical well-being, self-determination, material well-being, emotional well-being, and human and legal rights (Schalock, 2004; van Heijst & Geurts, 2015).

Conclusion

Ongoing reflection and development are the foundation of all great sciences. Applied behavior analysis is no exception. Behavioral practitioners recognize that they enter the field with an understandably finite set of specific skills. Throughout their career, they will be asked to both progress in those skills as well as gain new skills. Curriculum development may be one of those skills. Such development is not found in one book or one assessment. Practically speaking, it would be as impossible for someone to create a book with all the variations in skill acquisition, programming sequence, and treatment procedures needed for each client as it would be for someone else to then use that book to create an individualized treatment plan.

Better curriculum development comes not from better books but rather from a better process. Using the ADDIE model has proven effective in other fields to improve learning and to increase educational attainment. Still, this article does not provide empirical evidence to show that following the recommended actions will lead to better outcomes compared to following other actions. In the manner of Geiger et al. (2010), this article proposes a model that synthesizes the insights of a large body of empirical literature, this time related to skill development for clients with autism. The ADDIE model offers a systematic way for behavioral practitioners to reflect on their abilities in each area of instructional design. We encourage other papers and research that propose other key recommended actions in the assessment, design, development, implementation, and evaluation of treatment. We also encourage research that demonstrates which actions are critical to the ability to create high quality Comprehensive ABA Treatment.

This article hopes to provide a realistic process one can follow as a starting point for better programming. The article also hopes to provide recommended actions that can substantially improve one’s ability to create Comprehensive ABA Treatment. Finally, the article hopes to provide behavioral practitioners with helpful resources for each step of the process. Behavioral practitioners enter the field of ABA with varied backgrounds in the application of ABA. Some practitioners receive significant early experience in decreasing challenging behavior. Other practitioners receive significant early experience in rapid skill development. Still others receive significant early experience in the assessment process for comprehensive ABA therapy whereas others receive significant early experience in teaching technicians to implement therapy correctly. Quality ABA treatment requires significant experience in multiple areas. We encourage behavioral practitioners to continue to grow and hone the knowledge and experience they gained in college or early in their careers.

Such growth may require the help of a mentor (Brown et al., 2023; LeBlanc, Taylor et al., 2020a, 2020b). It must admitted that even as we have tried to create a framework that is easy enough for someone to follow, we recognize that the recommendations in this article may seem overwhelming. This process is not one that is completed in a day. The process may take years of practice, and finding an experienced mentor may be helpful in working through this model. At the same time, the beauty of this model is that it allows for gradual development. We believe that the best way to improve most professional behaviors is through a shaping process. To begin a journey toward improved Comprehensive ABA Treatment, it does not matter with which recommended action you begin or how much you set out to achieve. It simply matters that you take one small step forward. Individualized, high quality programming requires behavioral practitioners to seek more, take risks, and go beyond what may be known and comfortable to what is unknown and uncomfortable, all within a science-based, values-informed, systematic approach.

Data Availability

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study

Declarations

Competing Interests

No funding was received for the completion of this article. All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest in the materials discussed in this article.

Ethical Approval

This article does not contain any studies with human participants or animals performed by any of the authors.