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. 2020 Aug 17;13(4):838–848. doi: 10.1007/s40617-020-00453-8

Education for Children With ASD in South Korea: A Case Study

Hyesuk Lee Park 1, Lin Du 2,✉, Jinhyeok Choi 3
PMCID: PMC7666265  PMID: 33269194

Abstract

In South Korea, there is currently a massive gap between the demand and the supply of quality applied behavior analysis (ABA) services for children with autism spectrum disorder (ASD) and their families. However, the literature on the implementation and effectiveness of ABA intervention mainly comes from Western countries, and the voices of Asian countries are scarcely heard. The present article reports data collected from the KAVBA Center in Seoul, South Korea, as a direct replication of the CABAS educational model. Eleven 3- to 4-year-old children with ASD were the participants in the study and attended the center for 1 year. Our pre- and postintervention data show that the CABAS model provided an effective and cost-efficient service for children with ASD in South Korea.

Electronic supplementary material

The online version of this article (10.1007/s40617-020-00453-8) contains supplementary material, which is available to authorized users.

Keywords: ABA, ASD, CABAS, EIBI, South Korea

Autism spectrum disorder (ASD) is a developmental disorder that affects individuals’ language function and social-communication levels (Lord, Rutter, DiLavore, & Risi, 1999). These deficits have lifelong impacts on individuals and their families. Research has shown that early diagnoses and subsequent early intervention are effective in improving or even reversing the manifestation of ASD symptoms, as well as reducing the cost for lifelong supports and education (Eldevik et al., 2009; Hayward, Eikeseth, Gale, & Morgan, 2009; Klintwall, Eldevik, & Eikeseth, 2015; Peters-Scheffer, Didden, Korzilius, & Sturmey, 2011; Virues-Ortega, 2010). Young children who receive a high number of quality interventions based on behavior analysis for an extended period (i.e., 2 years) a significantly better prognosis (Hayward et al., 2009, b). Therefore, an established system is key to success in early intensive behavioral intervention (EIBI) services for young children with ASD.

According to the Centers for Disease Control and Prevention (CDC), ASD prevalence has been rising dramatically in recent years in the United States (CDC, 2019). Additionally, research has shown that the prevalence of ASD in South Korea was comparable to that of Western countries. Kim et al. (2011) used a total population sample and reported that ASD affected 2.64% of school-age children, equivalent to 1 in 38 children. Despite South Korea traditionally placing a high value on schooling and its well-known, exceptional-quality general education, available resources and services for students with ASD were rather limited (Kim et al., 2019).

Aside from the limited schooling options, there is little support from the government for EIBI services in the country (Lee et al., 2017). Specifically, interventions and therapies for ASD have not been covered by the country’s health care system (Korean National Health Insurance). Therefore, the costs for these students’ education come almost exclusively from parents’ payment (Kim et al., 2019).

As such, the call for quality education and trained professionals and trained professionals for this population is urgent. Currently, there are only 3 Registered Behavior Technicians, 33 Board Certified Assistant Behavior Analysts, 89 Board Certified Behavior Analysts, and 11 doctoral-level BCBAs in the whole country (Behavior Analyst Certification Board, 2019). At the same time, the Korean Ministry of Education (2019) reported there were 5,424 individuals with ASD. The total number of professionals is insufficient to serve these thousands of individuals with ASD.

We thus turned to the rest of the world in trying to find a model we could replicate. Although applied behavior analysis (ABA) has been widely recognized as an evidence-based science and authentic intervention treatment in North America, this is not always the case in other countries due to complex political, economic, and cultural factors (Ardila, 2006; Liao, Dillenburger, & Buchanan, 2018). In many European countries, ABA has not been endorsed at the national level. In practice, the understanding of ABA as a science has been inconsistent, and ABA is often treated as a collection of various behavior modification tactics (see Keenan et al., 2015, for a review). In other countries, such as Japan (Hiraiwa, 2016) and China (Chang & Zaroff, 2017; Clark, Zhou, & Du, 2019), although the effectiveness of ABA therapy has been established with the general public, its application has been modest and mostly through private agencies that mainly focus on service delivery. The countries lack a comprehensive system that incorporates structured professional training and effective parent training within the treatment of children with ASD.

We recognized that what the children and their families require is a systematic application of evidence-based behavioral interventions: a model that could benefit all parties, including the children, their families, and even the teachers (who could influence generations of children). We were able to find such a model, which has been established and tested over the past three decades. Known as CABAS, the Comprehensive Application of Behavior Analysis to Schooling model has been a complete educational model since its inception (Greer, Keohane, & Healy, 2002; Lamn & Greer, 1991; Selinske, Greer, & Lodhi, 1991). This educational model features student-centered instruction, teacher training, parent education, and supervisory support (Greer, 1997, 2002).

Over the past 30 years, the CABAS model has been applied and tested in numerous classrooms and schools serving children with and without developmental delays and disabilities in New York, New Jersey, Louisiana, and Virginia (see the CABAS website, www.cabasschools.org) in the United States. The model has also been replicated in several other countries, including England (Hawkins, Charnock, & Gautreaux, 2007), Ireland (Healy, O’Connor, Leader, & Kenny, 2008), Italy (Casarini, Cattivelli, & Cavallini, 2011; Lamn & Greer, 1991), and Spain. Its significant student learning outcomes that resulted from its scientific pedagogical and classroom management strategies provide the best proof that teaching is a science.

Our article therefore discusses a recent effort to bring this evidence-based model into Asia, which is often stereotyped for producing superior testing scores in the general education system (Organisation for Economic Co-operation and Development, 2019). Can the CABAS model provide benefits to students from such a drastically different cultural background? If so, in what areas and to what extent?

Method

Participants

The participants in this study were 11 preschool boys diagnosed with ASD, aged from 3 to 4 years. All participants were enrolled in the Korean Advancement of Behavior Analysis (KAVBA) Children’s Center from the beginning of the school year and received intervention continuously throughout the year. Three participants attended the full-day program and received 21 hr of ABA intervention per week. The other eight participants attended the half-day program and received 12 hr of ABA intervention per week. Please see Table 1 (full day) and Table 2 (half day) for the presence and absence of participants’ academic readiness, verbal behavior, play skills, and self-management skills. We have combined the participants’ repertoires before and after the intervention in the same tables for easier comparison.

Table 1.

Full-Day Class Participants’ Repertoires Pre- and Postintervention

Child 1 Child 2 Child 3
Pre Post Pre Post Pre Post
Academic Readiness Generalized visual matching with pictures Y Y Y Y Y Y
Generalized visual matching with objects Y Y Y Y Y Y
Pointing to pictures of different categories N Y N Y N Y
Sorting items based on categories N Y N Y N Y
Verbal Behavior Following 1-step vocal directions N Y N Y N Y
Imitating 1-step actions N Y N Y Y Y
Echoics N Y N Y N Y
Mands N Y N Y N Y
Tacts N Y N Y N Y
Intraverbal responses N Y N N N Y
Textual response N N N N N N

Play Skills /

Self-Management

 Imitating object use Y Y N Y Y Y
Performing school routines N Y N Y Y Y
Potty training N Y N Y N Y
Appropriate toy playing Y Y N Y N Y
Scripted playing N N N N N N
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Note. Y = yes; N = no

Table 2.

Half-Day Class Participants’ Repertoires Pre- and Postintervention

Child 4 Child 5 Child 6 Child 7 Child 8 Child 9 Child 10 Child 11
Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post
Academic Readiness Generalized visual matching with pictures Y Y Y Y N Y N Y Y Y N Y Y Y Y Y
Generalized visual matching with objects Y Y Y Y Y Y N Y Y Y N Y Y Y Y Y
Pointing to pictures of different categories Y Y N Y N Y N Y Y Y N Y Y Y Y Y
Sorting items based on categories N Y N Y N Y N Y N Y N Y Y Y Y Y
Verbal Behavior Following 1-step vocal directions N Y N Y N Y N Y N Y N Y N Y Y Y
Imitating 1-step actions Y Y N Y Y Y N Y Y Y Y Y Y Y Y Y
Echoics Y Y N Y Y Y Y Y Y Y Y Y Y Y N Y
Mands N Y N Y N Y N Y Y Y N Y Y Y N Y
Tacts N Y N Y N Y N Y N Y N Y N Y N Y
Intraverbal responses N Y N Y N Y N Y N Y N Y Y Y N Y
Textual responses N N N N N N N N N N N N N Y N Y

Play Skills /

Self-Management

 Imitating object use Y Y Y Y N Y N Y N Y N Y Y Y Y Y
Performing school routines N Y N Y N Y N N Y Y Y Y Y Y Y Y
Potty training N Y N Y N Y N Y Y Y N Y Y Y Y Y
Appropriate toy playing N Y N Y Y Y N N N Y N N Y Y Y Y
Scripted playing N N N N N N N N N N N N N N N Y
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Setting

All participants in the study attended the KAVBA Center for children with developmental delays. The KAVBA Center is a private agency established in 2016 in Seoul, South Korea. The center uses a behavior-analytic model of instruction and curricula and directly replicates all the key components of CABAS. The full-day program lasts from 10:00 a.m. to 3:15 p.m., Monday through Friday (except Wednesday for staff development). The half-day program starts in the afternoon, going from 1:00 p.m. to 3:15 p.m., Monday through Friday (except Wednesday for staff development). Each class has one program supervisor (who oversees two classes), one head teacher, two intern teachers, and two teacher assistants. The teacher-to-student ratio during instruction is one to one in all classes. There is a designated toy area with books and toys in each classroom. Parents waited in the parents’ lounge while their children received the intervention.

Dependent Variables

The first dependent variable was the participants’ Psychoeducational Profile–Revised (PEP-R; Schopler, Reichler, & Bashford, 2005; Schopler, Reichler, Bashford, Lansing, & Marcus, 1990) scores before and after the intervention. PEP-R is a standardized assessment to evaluate students’ developmental progress. The test assesses seven important developmental domains, as well as the interfering behavior during observation. We chose PEP-R for the following reasons: First, PEP-R has been translated into many languages (e.g., Brazilian, Chinese, Dutch, Korean). We used the translated Korean-language version of the test (Schopler et al., 2005). Second, PEP-R is known for its dual functions, serving as both an assessment and a curriculum-planning tool. With the results of the assessment, PEP-R assists in the design of individualized intervention programs for children with ASD and other developmental disorders (Portoghese et al., 2009). Third, PEP-R is easy to administer, as it has flexible presentation sequences and no time limit (Portoghese et al., 2009). It requires minimal language skills and measures developmental age (Alwinesh et al., 2012). Fourth, PEP-R has been a common assessment for clinical and research purposes, especially as an outcome measure for treatment effectiveness (Villa et al., 2010). In the KAVBA Center, classes’ head teachers and supervisors conducted the PEP-R for each student and calculated the total developmental score at the beginning and at the end of the school year.

The second dependent variable was the number of long-term objectives in the CABAS International Curriculum and Inventory of Repertoires for Children From Preschool Through Kindergarten (C-PIRK) before and after the intervention. C-PIRK (Greer & McKorkle, 2003; Waddington & Reed, 2009) is an instructional curriculum and assessment that evaluates students’ overall achievement records. It encompasses four major domains: academic literacy and communication, community of reinforcers, self-management, and physical development. The instrument identifies the key repertoires to prepare children for mainstream education (Waddington & Reed). The total number of C-PIRK objectives was calculated by adding up all long-term objectives that the student had accomplished in all four domains.

CABAS Education Model

During the 1-year intervention at the KAVBA Center, the participants were recipients of the CABAS education model. The model featured learn units, evidence-based curriculum and assessment, verbal behavior developmental protocols, a decision protocol, and ongoing teacher and parent training.

Learn unit

In the KAVBA Center, a learn unit was the smallest unit of measurement that tracks the interlocking three-term contingencies between the student and the teacher (Albers & Greer, 1991; Greer & McDonough, 1999). The learn unit considered a student’s current motivational conditions, current environment, instructional histories, and phylogenetic makeup (Greer, 2002). Therefore, students were not merely passive receivers or the end consumers of education. Instead, they played an active role in their learning. Similarly, teachers were not solely responsible for “presenting” instruction. Instead, the teacher was a strategic scientist who acted in response to the students. In other words, the student’s and teacher’s behaviors were mostly “interlocking with” each other. The learn unit required the teacher to make moment-to-moment decisions in her teaching based on the student’s current status, as well as any relevant changes in the student’s environment. If a student was not motivated or not attending, a learn unit was at fault. The teacher thus presented the learn unit again to the student.

At the end of each school day, teachers graphed the number of learn units they delivered during the day. At the end of the week, teachers summarized the data from the whole week and reported the total number of learn units, short-term objectives, long-term objectives, and learn units to criterion (i.e., how fast a student learns and how efficient a teacher teaches). In the KAVBA Center, all class-wide data were publicly posted. All these efforts helped provide a continuous performance-monitoring system.

Curriculum and assessment

As in all other learner-driven CABAS schools, students’ learning and progress were always at the heart of the whole educational system at the KAVBA Center. The center followed the same set of assessments and curriculum, C-PIRK (Greer & McCorkle, 2003) and the Verbal Behavior Development Assessment (Greer & Ross, 2008). All contents were directly translated from the original English version, except for a small number of reading objectives modified and adapted to Korean phonemic structures and syntax (Greer & Ross, 2011). C-PIRK was used to assess the students’ existing behavioral repertoires through direct observation. It encompassed academic literacy (i.e., general knowledge, basic concepts, reading, writing, math), communication (i.e., listening and speaking), self-management (i.e., potty training, cleaning up after eating), community of reinforcers or interests (e.g., toys, books, blocks, arts, science, and other age-appropriate activities), and physical development (i.e., jumping, climbing up and down the stairs).

Unlike most other assessment instruments, C-PIRK also functioned as a curriculum to teach students any missing repertoires. Based on the assessment results, teachers selected appropriate repertoires that were absent and set up correspondent programs to teach those skills. This arrangement helped ensure that the types of objectives chosen for the student were suitable, regardless of the years of experience and expertise of the student’s teacher. Teachers conducted the assessment regularly (two to three times a year) to capture students’ most up-to-date educational and social gains (as well as possible regressions).

In the KAVBA Center, students’ instruction was individualized based on their strengths and needs. Thus, a curriculum based on a functional account of verbal behavior such as C-PIRK was a core element of early intervention for children with ASD at the center. Further, using C-PIRK closely aligned to verbal development milestones (Greer, 2002; Greer & Ross, 2008) was essential for the development of verbal capabilities. Acquiring new verbal abilities as behavioral cusps enables children to learn new skills in ways in which they were previously incapable (Greer & Du, 2015; Greer, Pohl, Du, & Moschella, 2017; Greer & Speckman, 2009). The KAVBA Center incorporated features of direct instruction, the personalized system of instruction, and programmed instruction, among other curricula, in daily teaching practices.

Verbal behavior development protocols

Over the years, CABAS has identified a series of verbal behavior interventions and protocols (Greer & Ross, 2008; Greer et al., 2017) that could substantially facilitate the induction of students’ verbal repertoires.

When learning plateau occurs and standard instruction and tactics are not effective, the student may be lacking certain key developmental milestones (Greer & Ross, 2008). Research has indicated that these protocols may be necessary to establish missing verbal behavior developmental cusps. These protocols are not about teaching children new things (e.g., curricular objectives), but rather about changing the way children learn, thus allowing them to learn things they could not do before (Hawkins et al., 2007). These protocols were highly effective in providing the missing experiences the students needed and in establishing the conditioned reinforcement to induce students’ verbal behavior developmental cusps or capabilities (Greer & Du, 2015).

At the KAVBA Center, these intervention protocols helped identify and evoke verbal behavior developmental cusps and capabilities for students in need. For example, the teachers used an auditory matching protocol (Choi, Greer, & Keohane, 2015) and a voice conditioning protocol (Greer, Pistoljevic, Cahill, & Du, 2011) for students who could not follow teachers’ vocal directions. When the students mastered the protocols, their learn units to criterion in relevant programs (i.e., pointing to a picture, following one-step vocal directions) decreased substantially. For students who lacked spontaneous speech, especially in noninstructional settings, a speaker immersion protocol (Pistoljevic, Cahill, & Casarini, 2010; Ross, Nuzzolo, Stolfi, & Natarelli, 2006) was used to help them increase their pure mands and tacts. (Please see Table 3 for a list of sample protocols and the verbal behavior cusps/capabilities they induce.) Parents also routinely reported increases in their children’s language development at home and in the community.

Table 3.

Sample Verbal Behavior Protocols Implemented in the KAVBA Center

Protocol Verbal Behavior (VB)
Cusps/Capabilities Induced		 References
Voice conditioning protocol Adults’ voices as reinforcing stimuli for listening, a VB cusp that enables the child to orient toward adults’ voices Greer, Pistoljevic, Cahill, and Du (2011)
Auditory matching protocol Phonemic discrimination as a listener, a VB cusp that enables the child to discriminate between positive and negative auditory exemplars by matching auditory stimuli Choi, Greer, and Keohane (2015)
Mirror protocol Generalized imitation, a VB cusp and capability that enable the child to have the see-do correspondence and imitate novel movements Du and Greer (2014)
Listener emersion protocol Listener literacy, a VB cusp that enables the child to respond to spoken instructions without any visual cues Greer, Chavez-Brown, Nirgudkar, Stolfi, and Rivera-Valdes (2005)
Speaker immersion protocol Independent mands, a VB cusp that enables the child to establish the correspondence between production and delivery of a reinforcer and emit vocal operants under deprivation Pistoljevic, Cahill, and Casarini (2010) and Ross, Nuzzolo, Stolfi, and Natarelli (2006)
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Teachers changed the types of learn unit presentations used based on the presence or absence of the student’s particular verbal behavior developmental cusps. For example, before students acquired bidirectional naming (Greer, Stolfi, Chavez-Brown, & Rivera-Valdez, 2005), a cusp that allows one to learn incidentally, they received standard direct learn units from the teacher. Once they had acquired bidirectional naming, they received the instructional demonstration learn unit, a more efficient type of learn unit that consisted of the teacher demonstrating correct responses for a few exemplars.

Decision protocol

Although visual displays helped teachers promptly identify data trends and variability, a systematic decision protocol was needed to make accurate and timely decisions to continue or discontinue the current program (Greer & Keohane, 2005). Research has shown that data-based decisions are associated with quality instruction: Decision protocols led to a decrease in students’ learn units to criterion (Keohane, 1997). Teachers in the KAVBA Center follow the basic decision algorithm to decide (a) to confirm mastery at 90% for two consecutive sessions or 100% accuracy for one session, (b) to continue at three successive ascending data paths, (c) to continue at five overall ascending data paths, (d) to stop at three successive descending data paths, and (e) to stop at five overall descending data paths. For any of the discontinued programs, teachers applied more advanced algorithms to identify solutions. This provided a strategic analysis of the source of the problem in the learn unit context (i.e., correct or incorrect curriculum/objective, student’s motivation, setting event, instructional history) and suggested tactics that were likely to be effective.

Parent education

As children’s lifelong teachers, parents have an indispensable role in their children’s lives. Research has shown that the quality of relations between schools and families plays an integral role in student success (Bibby, Eikeseth, Martin, Mudford, & Reeves, 2002; Rogers et al., 2014). From the very beginning, the KAVBA Center encouraged and supported parents’ participation in parent education and their involvement in all aspects of their children’s learning. As Kerr and Nelson (1989) pointed out, the goals for parent training were (a) to develop skills parents need to manage their children’s behavior at home and (b) to obtain parental support for classroom goals. Therefore, the center aimed to train parents to become competent and primary agents of change for their children and develop a well-established sense of mastery and confidence in their parenting skills. Yuan, Lee, and Kimmel (2018) demonstrated the importance of such education and support for families of children with developmental delays and disabilities. In the study, the parent educators provided a training package for all the participating parents and trained them to criterion in the training programs in the school. The parents carried out the same procedures at home and helped their children generalize the skills they had learned in school.

The KAVBA Center regularly provided a series of parent education sessions to students’ caregivers. The center first offered a 22-week education program for parents, and then it created a parent education curriculum. The curriculum included basic concepts and terms of ABA and verbal behavior analysis, the delivery of learn units as an operant conditioning procedure with practicum sessions, and play skills. The center then offered another 4-week advanced program to parents who had completed the first program. These continuing programs provided parents with a basic understanding of their children’s language development and social interaction and taught parents how to set appropriate goals at home, implement instructional sessions, monitor targeted behavior changes, and promote desired behavior generalizations.

Teacher training

In the CABAS model, teachers are strategic scientists who can analyze problems in students’ learning and come up with evidence-based solutions for those problems (Greenberg & Chung, 2019). Unlike other business models, in the KAVBA Center, the initial staff training only made up one small portion of the rigorous training for the staff. All teaching staff in the center attended presession training and had continuous on-the-job training. Teacher trainees were calibrated to 100% accuracy on their instruction presentation before they delivered instruction independently. By using the Teacher Performance Rate and Accuracy Scales, or TPRAs (Ross, Singer-Dudek, & Greer, 2005), supervisors directly observed the teachers’ teaching performance and the students’ learning. For the teacher’s performance, TPRAs measured whether the teacher selected the correct curriculum objective, used the correct educational materials, ensured the presence of the correct motivation operation, and delivered an intact learn unit with a three-term contingency. For the student’s learning, TPRAs allowed the supervisor to record the student’s response data and detect if there were any error patterns.

At the end of each observation, the supervisor compared the recorded correct and incorrect number of student responses with the teacher’s responses and checked for point-to-point correspondence. The results included the percentage of correct and incorrect student responses and the percentage of correct and incorrect teacher responses. The results from the TPRA form provided interobserver agreement (IOA) for the intervention sessions and ensured treatment fidelity. These frequent teacher performance measurements also offered ongoing training and performance tracking for teachers and teachers in training.

The KAVBA Center also held weekly teacher training workshops to keep all teachers up-to-date with their professional development. These year-round workshops covered the topics of basic instructions, common instructional errors, advanced teaching protocols, and recent research findings, among others. In the weekly supervision meeting, teachers needed to take quizzes on basic concepts and principles of behavior analysis, recycled to criterion. Teachers took turns presenting graphs with possible problems in a learn unit context. They followed decision protocols to identify learning problems and to select research-based tactics. The quick graph presentation was an essential element of the teacher training package and helped establish their problem-solving and verbally mediated repertoires.

Everyone (including the director) at the KAVBA Center was required to work on their teacher ranks, starting from Teacher 1, and moving to Teacher 2, Master Teacher, Behavior Analyst, and Research Scientist. Each teacher rank included verbal behavior about the science, contingency-shaped repertoires, and verbally mediated repertoires. As of this study, all direct-teaching staff at the center have obtained the CABAS Teacher 1 rank. Teachers were rewarded with an immediate increase in their salary once they obtained each teacher rank.

Interobserver Agreement (IOA)

For the first dependent variable, PEP-R was conducted by the participants’ head teachers and class supervisors, who strictly followed the guidelines from the publisher of the assessment. Unfortunately, there was no independent observer available at the time to take IOA data.

For the second dependent variable, the C-PIRK assessments were built into the students’ instruction. Supervisors independently and simultaneously conducted TPRAs on teachers and teacher assistants. At the end of each observation, they compared the student’s (as well as the teacher’s) responses that had been recorded and calculated the percentage of agreement by dividing the number of agreements by the number of point-to-point agreements plus disagreements and multiplying the answer by 100%. There was a total of 624 errorless TPRAs and 60 TPRAs with errors done for all students’ instruction during the 1-year intervention. That is, IOA was 91.2% for the selected instruction during supervision.

Results

We measured and graphed all key elements of the CABAS model of education, including the number of weekly learn units, short-term objectives, learn units to criterion, TPRAs, and decisions for each student, teacher, classroom, and the whole center. The weekly center-wide graphs are available in the Supplementary Material (Figs. 1-5). Although there were only 1 year’s data available at this time, all participants made significant educational gains as a result of their learning at the KAVBA Center. After the intervention, all participants showed improved listener and speaker responses. Most of them learned to imitate motor movements, follow simple vocal directions, discriminate different stimuli by pointing, and begin to use words (or word approximations) functionally in mand or tact format. Some of them even learned intraverbal responses or to textually respond to stimuli in print.

Most notably, the participants’ progress was reflected in their increased PEP-R scores and C-PIRK objectives. Table 4 shows the participants’ pre- and postintervention PEP-R scores and gains. Before the intervention, the participants were functioning at an average of 13.7 months developmental age equivalents (with a range from 10 to 30 months) based on their PEP-R assessments. After the intervention, the average developmental gain across participants was 27.6 months, with an ranging from 16 months to 50 months. More than half of them showed at least a whole year’s developmental increase and narrowed their developmental gaps with their typically developing peers.

Table 4.

Pre- and Postintervention PEP-R Scores and C-PIRK Objectives Met

Child Age Class PEP-R C-PIRK
Pre Post Gains Pre Post Gains
1 3 years 6 months Full 10 29 19 24 80 56
2 3 years 7 months Full 10 17 7 12 84 72
3 4 years Full 10 35 25 13 99 86
4 4 years 1 month Half 13 25 12 53 131 78
5 4 years 3 months Half 16 23 7 32 118 86
6 4 years 5 months Half 10 16 6 25 122 97
7 4 years 7 months Half 10 20 10 37 104 67
8 4 years 10 months Half 13 29 16 50 167 117
9 4 years 5 months Half 10 20 10 21 71 50
10 5 years 5 months Half 19 40 21 93 127 34
11 4 years 8 months Half 30 50 20 55 179 124
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Note. PEP-R pre- and postintervention data were reported in months

We conducted a paired-samples t test and found that students gained 13.9 months in their PEP-P assessment on average, with a range of 7 to 25 months. Due to the small sample size, a stricter p value, 0.001, was used to control for Type 1 errors. The participants showed an increased developmental age after the 1-year intervention (M = 27.64, SD = 10.51) compared to when they had started (M = 13.73, SD = 6.18), t(10) = 7.01, p < .0001.

Table 4 shows the pre- and postintervention number of mastered C-PIRK objectives during the yearlong intervention. Before the intervention, the students had mastered 12 to 93 long-term objectives in the C-PIRK assessment, with an average of 38. After the 1-year intervention, they showed mastery of 71 to 179 long-term objectives, with an average of 124. The participants’ educational gains in the four developmental domains ranged from 34 to 117 long-term objectives, with an average of 79. When comparing the participants’ improved objectives to their individual preintervention data, we found that the improvement ranged from 37% to 661%, with an average of 292%. After the intervention, the participants mastered significantly more C-PIRK objectives (M = 116.55, SD = 34.25) compared to when they had started (M = 37.73, SD = 23.82), t(10) = 9.56, p < .0001 (a stricter p value, 0.001, was used to control for Type 1 errors).

After reviewing all the students’ outcome data, we conducted a cost-benefit analysis. Throughout the yearlong intensive behavior intervention, the students received a total of 542,706 learn units and achieved 7,247 short-term objectives, and the total cost for the services was ₩426,265,089 (equivalent to $354,345). Therefore, the cost per learn unit was ₩785 (equivalent to $0.65), and the cost per objective was ₩58,819 (equivalent to $48.90). After comparing these costs with those of other CABAS model centers (Greenberg & Chung, 2019; Greenberg & Martinez, 2008; Greer, 1994), we found that the cost per learn unit and cost per short-term objective at the KAVBA Center were among the lowest (after adjusting for inflation). Please see Table 5 for details.

Table 5.

Comparison of Costs of a Learn Unit and Objectives From Other Schools and Centers With the CABAS Model

Research Cost per Learn Unit Cost per Learn Unit
(Adjusted)		 Cost per Objective Cost per Objective
(Adjusted)
Greer (1994) $0.84 $1.40 $55.58 $94.40
Greenberg and Martinez (2008) $0.52 $0.59 $69.68 $79.2
Greenberg and Chung (2019) $0.90 $0.90 $86.66 $86.66
The KAVBA Center $0.65 $0.65 $48.90 $48.90
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Discussion

Our data supported the findings from other research that shows EIBI is highly effective and offers a highly promising prognosis (Chasson, Harris, & Neely, 2007; Klintwall et al., 2015; Sallows & Graupner, 2005). Our study also replicated the same exciting results from other CABAS sites and extended the findings to Asia. All participants in the current study expanded their listener literacy, developed their speaker repertoires, and improved their self-management skills. The progress demonstrated a reduced developmental delay in these participants. The results are aligned with previous research that has shown that EIBI training at an early age is likely to result in considerable improvement (Howard, Stanislaw, Green, Sparkman, & Cohen, 2014). Furthermore, six participants gained at least 1 year (12 to 20 months) in developmental-age-equivalent performance after the intervention. This is worth noting, as it suggests an accelerated learning rate that could positively influence the participants’ subsequent learning outcomes. We postulate the positive change to be the outcome of acquiring prerequisites and establishing the missing behavior cusps and capabilities, which allow the children to learn new things and learn in ways that they could not before (Pohl, Greer, Du, & Moschella, 2018).

Our data show that the participants from both the full-day and half-day programs made drastic developmental progress. We posit that “intensive” behavioral intervention should not just be about the sheer number of behavioral training hours. More importantly, it needs to be about quality, including curriculum and assessment, evidence-based decision making, high-quality training, and ongoing supervision for the staff (Eikeseth, Hayward, Gale, Gitlesen, & Eldevik, 2009; Greer et al., 2002).

The KAVBA Center in Seoul provided evidenced-based applied behavior principle as education, data-based instructional decision EIBI services to children with ASD. Establishing and maintaining the CABAS model in Korea were crucial elements in disseminating ABA as scientifically based education. In addition to the systematic replication of the CABAS model for the first time in an Eastern cultural context, the Korean translation of the book Verbal Behavior Analysis (Greer & Ross, 2008, 2011) was an effective measure in disseminating an EIBI model.

In addition, evidence from the KAVBA Center also shows that behavioral intervention can be cost-efficient. This topic is especially important, given the fact that Korean parents pay for all their children’s behavioral intervention. New research findings, such as the decision algorithm and verbal behavior intervention protocols, substantially improved productivity during the intervention and positively impacted the students’ learning outcomes. The CABAS decision protocol (Greer, 2002; Greer & Keohane, 2005; Keohane, 1997) provided a standard method to gauge students’ progress and learning. By instructing teachers to respond to students’ instructional problems in a timely fashion, the decision protocol led to considerable savings in students’ instructional time and more effective teaching. The verbal behavior intervention protocols, derived from verbal behavior development theory and research, successfully induced the missing developmental cusps and capabilities in the students, which resulted in a drastically faster acquisition rate in their learning objectives (Greer et al., 2017; Greer & Ross, 2008). All these new research findings and their direct application to teaching practices for students have helped to decrease the cost of every learn unit presented and objective achieved at the KAVBA Center.

One limitation of the study was the lack of IOA data for individual participants. As supervisors had other responsibilities (e.g., program planning and parent education), they were not able to observe all participants’ assessment and instructional sessions. In the KAVBA Center, classroom supervisors conducted daily TPRAs on teachers as part of staff training. Once the teachers’ responses reached criterion (e.g., 100% IOA in TPRAs for three consecutive sessions in one domain), they ran more independent instruction with their students. Supervisors continued to conduct regular TPRAs to ensure the integrity of implementation during assessment and instruction. It is worth noting that the average number of TPRAs per student at the center was significantly more than that of other CABAS sites (Singer-Dudek, Speckman, & Nuzzolo, 2010).

One of the main limitations is the simple pre- and postintervention probe design. The design cannot exclude the influence of other confounding variables and was certainly not optimal for a true experimental design. Future research should consider using a more stringent experimental design (i.e., multiple-probe design, multiple-baseline design) that could exert better experimental control and establish more validity of the intervention procedure. Recognizing the limitation of the design, we conducted a statistical analysis of the group data, and the significant gains made between the pre- and postintervention conditions helped provide convincing evidence for our study.

The study would have benefited from reporting more supplementary standard test scores for the participants. The current study only included two main dependent variables with one standard test. Although the PEP-R is a common instrument used in South Korea to assess the developmental age of children with ASD, using other instruments would have yielded more participants’ information and allowed for a confirmation of the current test scores. This limitation was partly due to the lack of available standard evaluation instruments in the Korean language. We thus provided herein relatively detailed demographic information for each participant and hope this will help create more complete profiles for the participants. 

In conclusion, our study provided preliminary data to support a successful replication of the CABAS model in the East. With similar ASD prevalence and educational challenges (Clark et al., 2019; Greenberg & Chung, 2019), other Asian countries may face situations like the one in South Korea. Although more large-scale international collaboration is needed, we hope the experiences at the KAVBA Center will shed some light on other countries’ search for the best model they need.

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Compliance with Ethical Standards

Conflict of Interest

The first author is the founder, owner, and director of the KAVBA Center and the KAVBA Center is a private, for-profit agency in Seoul, South Korea. The second and corresponding author declares that she has no conflict of interest. The third author consults at the KAVBA Center.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the KAVBA Center and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

Footnotes

Publisher’s Note

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

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