Rev J Autism Dev Disord DOI 10.1007/s40489-016-0073-1

REVIEW PAPER

An Overview of Autism and Applied Behavior Analysis in the Gulf Cooperation Council in the Middle East Michelle P. Kelly 1 & Ingy Alireza 2 & Heather E. Busch 3 & Sarah Northrop 4 & Mohammad Al-Attrash 5 & Susan Ainsleigh 6 & Nipa Bhuptani 7

Received: 12 November 2015 / Accepted: 2 March 2016 # Springer Science+Business Media New York 2016

Abstract Despite the fact that autism is on the rise, there is paucity in the literature examining the treatment of autism in the Middle East and specifically the Gulf Cooperation Council (GCC). The current review investigates the past, present, and future status of interventions for autism based on Applied Behavior Analysis (ABA) in the six countries of the GCC, namely the Kingdom of Bahrain, the State of Kuwait, the Sultanate of Oman, the State of Qatar, the Kingdom of Saudi Arabia, and the United Arab Emirates. The aims of this paper were to provide a brief overview of autism and ABA clinical services and educational opportunities and to investigate the relevant research published from each of the six states of the GCC.

Keywords Applied Behavior Analysis . ABA . Intervention . Evidence-based practice . Middle East . Gulf

* Michelle P. Kelly [email protected]

1

Counselling, Health and Special Education Division, Emirates College for Advanced Education, P.O. Box 126662, Abu Dhabi, United Arab Emirates

2

Think Behavior and Development Center for Children, Saar, Bahrain

3

Applied Behavior Center of Kuwait, Kuwait City, Kuwait

4

Voyage Care, Lichfield, UK

5

Shafallah Center for Children with Special Needs, Doha, Qatar

6

Jeddah Institute for Speech and Hearing, Jeddah, Kingdom of Saudi Arabia

7

Autism Support Network—Abu Dhabi, Abu Dhabi, United Arab Emirates

The prevalence of autism is on the rise all over the world (Ouhtit et al. 2015). The current estimate by the American Autism and Developmental Disabilities Monitoring Network is as high as 1 in 68 individuals with a diagnosis of autism (Centers for Disease Control and Prevention 2014). Although similar rates have also been found across Europe (Hughes 2011), there have been a limited number of studies conducted in the Middle East and specifically the Cooperation Council for the Arab States of the Gulf (also known as the Gulf Cooperation Council). The Gulf Cooperation Council (GCC) was established in 1981 in Abu Dhabi and consists of six member states: the Kingdom of Bahrain, the State of Kuwait, the Sultanate of Oman, the State of Qatar, the Kingdom of Saudi Arabia, and the United Arab Emirates (Cooperation Council for the Arab States of the Gulf 2012). The population of the GCC has more than doubled since 1990 and currently is approximately more than 47 million people (Cooperation Council for the Arab States of the Gulf 2012). Table 1 shows the approximate population (from 2012) in each of the six member states of the GCC. Salhia et al. (2014) conducted a systematic review of the epidemiology of autism in the GCC and reported a prevalence rate ranging from 1.4 to 29 per 10,000 individuals. It is imperative that each member state offers adequate intervention options to their residents with autism, especially as these prevalence statistics are likely to be underestimates (Hughes 2011; Ouhtit et al. 2015). This issue will be discussed further in later sections. Disabilities can be highly stigmatized in the GCC region and a family can face social repercussions for having a child or sibling with autism. Al-Kandari (2006) addresses stigmas attached to autism as being caused by cultural standards, parents’ lack of understanding, and misinformation given by doctors. Organizations and specialists throughout the GCC and

Rev J Autism Dev Disord Table 1 The estimated population (from 2012) and prevalence rates for autism in each of the six member states of the Gulf Cooperation Council (GCC)

GCC state

Estimated population (in millions)

Published prevalence rate

Kingdom of Bahrain

1.2

4.3 per 10,000 (Al-Ansari and Ahmed 2013)

State of Kuwait Sultanate of Oman

3.1 3.3

– 1.4 per 10,000 (Al-Farsi, Al-Sharbati, Al-Farsi, Al-Shafaee, Brooks and Waly 2011)

State of Qatar

2.7

–

Kingdom of Saudi Arabia United Arab Emirates

28.4 8.3

– 29 per 10,000 (with a diagnosis of PDD) (Eapen, Mabrouk, Zoubeidi, and Yunis 2007)

Middle East need to work together toward increasing awareness of autism to reduce this stigma so that each individual with autism can access effective intervention. Interventions based on Applied Behavior Analysis (ABA) have extensive international support as established treatments (National Autism Center 2009/National Autism Center 2015) that are effective for children with autism (Reichow 2012; Wong et al. 2015). The National Autism Center (2015) recently published a report that examined treatment for adults with autism and found that behavioral intervention is the only intervention that can be categorized as established for individuals aged 22 years and over. Behavior analysts aim to remove the barriers to learning that individuals with autism may face and to teach the functional skills that lead to independence and improved quality of life (Keenan et al. 2015). This process should be supervised by a behavior analyst certified by the Behavior Analyst Certification Board®, Inc. (BACB®; www.bacb.com). Table 2 shows the number of BACB certificants in each member state of the GCC (as of February 23rd, 2016). Table 2 also presents the number of Registered Behavior Technicians™ (RBT™), a new BACB credential that establishes training

Table 2 The total number of Board Certified Assistant Behavior Analysts (BCaBAs), Board Certified Behavior Analysts (BCBAs), Board Certified Behavior Analysts-Doctoral (BCBA-Ds), and Registered Behavior Technicians (RBTs) in each member state of the Gulf Cooperation Council (GCC; as of Feb 23rd, 2016) GCC state

BCaBAa

BCBA

BCBA-D

RBTa

Kingdom of Bahrain State of Kuwait Sultanate of Oman

1 2 0

3 3 0

0 0 0

9 0 0

State of Qatar Kingdom of Saudi Arabia United Arab Emirates Total

0 4 7 14

3 8 25 42

2 0 2 4

0 6 100 115

a

It is mandatory that each BCaBA and RBT practice under the supervision of a BCBA or BCBA-D (Behavior Analyst Certification Board, n.d.)

standards for individuals who implement behavior plans directly with clients. To become a BACB certificant, there are a number of criteria to fulfil. Upon completion of the necessary degree, training, and experience requirements, students are then eligible to sit for an examination, which must be passed to become a Board Certified Assistant Behavior Analyst® (BCaBA®) or Board Certified Behavior Analyst® (BCBA®). The training requirements state that individuals must complete a minimum number of hours in several content areas in college or university courses in behavior analysis. There are currently three BACB-approved course sequences (ACSs) in the GCC. BCaBA course sequences are offered in Jeddah, Kingdom of Saudi Arabia, and Abu Dhabi, United Arab Emirates, and a BCaBA/BCBA course sequence is offered in Riyadh, Kingdom of Saudi Arabia. The Association for Behavior Analysis International (ABAI 2015) was established in 1974 and is the primary membership organization for behavior analysts around the world. In October 2003, an ABAI delegation of six highly esteemed behavior analysts traveled to the GCC (Manama, Bahrain; Dhahran, Saudi Arabia; and Doha, Qatar) and presented a comprehensive introduction to ABA at the Middle East Applied Behavior Analysis Conference in Bahrain (Malott et al. 2003). The ABAI delegates also presented introductory and advanced seminars in autism and visited treatment centers for children with disabilities in Doha, Qatar, and Dhahran, Kingdom of Saudi Arabia. The delegation’s activities resulted, for many in the region, in an initial exposure to ABA. The delegation reported a tremendous need for services and a need for higher education opportunities in the region (Malott et al. 2003). Affiliated chapters are membership organizations associated with ABAI and are defined by a geographical boundary. The Middle East Association for Behavior Analysis (MEABA) was affiliated in 2002 and strives to promote the science of behavior within Middle Eastern countries (Alqassab 2015). In 2013, two affiliated chapters were established in the GCC, including ABA Saudi Arabia and United Arab Emirates ABA. Both chapters were created with

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the mission to disseminate ABA in their respective countries and to support the development of behavior analytic services for people in need, including individuals with autism (Association for Behavior Analysis International 2015). ABAI also provides financial support for the field of behavior analysis via the Society for the Advancement of Behavior Analysis (SABA; 2015). SABA’s International Development Grant has been awarded to three individuals in the GCC: to establish the MEABA chapter (Al-Qassab 2001); to support a parent training outreach project in Riyadh, Kingdom of Saudi Arabia (Fuller 2014); and to coordinate the translation of English behavior analytic terminology and literature into standard Arabic (Kelly 2014). This final project included translation of a glossary of behavior analytic terms, as well as the BACBs Fourth Edition Task List and the Professional and Ethical Compliance Code for Behavior Analysts. These documents are available via the BACB website. This translation task force is continuing to translate seminal articles and literature into Arabic. In October 2015, the BACB announced that their credentialing exams would be available in Arabic in February 2019, which is an important development to ensure sustainability of ABA in the GCC and Middle East. Other projects have focused on translating documents related to autism into Arabic. The Picture Exchange Communication System (PECS) training manual (Frost and Bondy 2002) was translated into Arabic and published by the Saudi Autism Charitable Society in 2009 (PECS-UK Resources 2015). In 2008, a team from the Arab Republic of Egypt, the Kingdom of Saudi Arabia, and the State of Qatar with the cooperation of Autism Speaks (2015) and Western Psychological Services (WPS 2015) began translating the Autism Diagnostic Interview™, Revised (ADI™-R; Rutter et al. 2003b) into Arabic. It was published in 2014 (Western Psychological Services 2015). The Modified Checklist for Autism in Toddlers, Revised with Follow-Up™ (M-CHAT-R/F™; Robins et al. 2009) was translated into Arabic by a team in Egypt and published in 2014. In 2013, the Verbal Behavior and Functional Skills Assessment for Individuals with Autism and other Developmental Disabilities (VBFSA IADD) was developed in Arabic in the State of Qatar (Al-Attrash and Al Sheyab 2015). This assessment aims to identify the strengths and weaknesses of each student in order that effective individual education plans (IEP) are developed. The Centers for Disease Control and Prevention (CDC 2014) has published three freely available documents in Arabic: a developmental screening fact sheet, a milestones card, and a fact sheet with tips for talking with parents. Furthermore, ABA undergraduate students in Abu Dhabi have developed an Arabic website about autism in the Middle East (http://www.autismmiddleeast.com/). This website contains many useful resources for Arabic-speaking parents of children

with autism including a series of video models for helping deal with the challenges of traveling by air (Ruddy et al. 2015). The current paper aims to provide an overview of the history and status of autism and ABA in each of the GCC member states. One behavior analyst from the field of autism was recruited from each state where they were currently or had previously resided and worked. This paper will allow all stakeholders to be informed about the regional needs in developing autism and ABA services and research and in increasing access to academic programs and training opportunities.

Kingdom of Bahrain Autism in Bahrain The only prevalence study conducted to date found 4.3 cases per 10,000 individuals with a male-to-female ratio estimated at 4:1 (Al-Ansari and Ahmed 2013). One contributing factor for the difficulty in determining accurate prevalence rates is the number of cases diagnosed outside of Bahrain. In the public sector under the Ministry of Social Development (2014), there are four treatment centers serving approximately 150 children with autism/development delays. The centers are generally oversubscribed, and waiting lists are common and range from 16 to 300 individuals. In the private sector, there are three centers and one special-needs school serving individuals with autism. Some private mainstream preschools and nursery settings with an inclusive philosophy admit children suspected to have autism and often provide shadow teachers. The progression into private mainstream education is often halted after preschool years. Schools refuse admission into primary and secondary education if the student demonstrates too many behavioral excesses and learning barriers to access the mainstream curriculum successfully (H. Al Khalifa, personal communication, December 11, 2014). ABA-Based Intervention for Autism in Bahrain Four centers that cater for individuals with autism report that ABA-based intervention is implemented, often in conjunction with other programs in an eclectic model (A.M. Al-Ansari, personal communication, December 10, 2014). In all but one setting, ABA programs are not monitored by an onsite BCBA. The high demand for services means that autism centers are often above capacity. Education and Training in Bahrain The Bahrain Society for Children with Behavioral and Communication Difficulties (2015) organizes biannual conferences with a different focus in each event. The 2013

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conference, BUntangle Autism,^ focused on medical and diagnostic topics related to autism. This society also organizes and hosts workshops by visiting consultants for families throughout the year. In 2014, the Ministry of Education held a Special Needs Support Exhibition. Many of the exhibitors were from regional franchises of clinics that provide ABAbased intervention internationally. Currently, there is only one university in Bahrain that provides a degree concentration in special education with a focus on intellectual disability and autism (Arabian Gulf University 2010).

State of Kuwait Autism in Kuwait In 1995, the government established the first funded center for autism with the help of the Directorate General of Religious Affairs, the Ministry of Education, and private sponsors (Fields 1996). This autism center, only the second of its kind in the GCC region (Fields 1996), provided services in Arabic to Kuwaiti nationals using the TEACCH method combined with sensory integration, music and art therapy, and behavior management. In 1996, the Kuwait government passed a law that addressed the needs of individuals with disabilities (Al-Hilawani et al. 2008). As a major step forward in the support of individuals with special needs, the law included specifications related to housing, rehabilitation centers, disability pensions, monthly allowances, and assistance with employment. In 1996, Fields estimated the population of children with autism in Kuwait to be over 500–700; however, it was reported by the Kuwait News Agency (2011) that Al Sabah Children’s Hospital diagnosed over 120 new cases of autism in 2010 alone. With the development of autism research and treatment in Kuwait being relatively new, it is still unclear as to the current prevalence of autism within the country.

ABA-Based Intervention for Autism in Kuwait The standards for implementation of ABA programs are still unknown by the general population in Kuwait, and there is a lack of clarity regarding the types of services offered. The credentials, clinical training, and quality of services vary greatly from clinic to clinic. More clinicians practice with high school diplomas (27 %) than those with graduate degrees (20 %) (Scull et al. 2014). Of seven centers listed as providing behavioral treatments, often in combination with other treatments, only one provides treatment in accordance with the BACB practice guidelines for healthcare managers (Kuwait Association for Learning Difficulties 2014).

Education and Training in Kuwait Al-Shammari (2006) argued that the Ministry of Education should provide educational programs for teachers in Kuwait to meet the demands in the field of autism treatment and to ensure that teachers are not ill prepared to teach students with autism. In order for individuals to become effective autism practitioners, it is important that they not only complete necessary coursework but also learn how to apply and practice what they learn. In the Kuwait Association for Learning Difficulties (2014) directory, there are five organizations listed that provided trainings to professionals and teachers in Kuwait. The focus of these trainings was not specified. A number of workshops and conferences take place each year to provide training to professionals in Kuwait. In 1999, the first International Conference on Autism and Communication Deficits in the Middle East was held in Kuwait (Kuwait Center for Autism 1999). This was part of the initiative to increase awareness and support throughout the Kuwaiti community. In 2006, a conference took place to emphasize the benefits of early diagnosis and intervention (AlHilawani et al. 2008). In 2014, Kuwait organized the World Autism Congress, which included presentations and workshops by autism specialists, including BCBA-Ds, from around the world.

Sultanate of Oman Autism in Oman Al-Farsi et al. (2011) estimated that 1.4 per 10,000 Omani children (aged 0–14 years) have been identified as having autism. The authors postulated that the low prevalence rate may be the result of underdiagnosis and underreporting of autism in the country and, therefore, may just be merely the Btip of the iceberg.^ (Al-Sharbati et al. 2015, p. 2). Al-Farsi et al. (2011) suggested that the underdiagnosis may be a result of the entire nation being serviced by a single child psychiatry unit located in the capital. Therefore, the majority of the population may find it logistically or financially challenging to reach the clinic for diagnosis and treatment. Other factors for the low prevalence rate may include cross-cultural variations in the expression of autism and the unreliability of diagnostic tools, especially with higher functioning individuals (Ouhtit et al. 2015). Additionally, Profanter (2009) suggests that, unfortunately, due to the stigma of having a child with special needs, there is a tendency in Oman to Bhide^ challenged children within the family household, therefore limiting their access to educational or remedial services. Furthermore, Hughes (2011) reports that the low prevalence is a product of the methods used. Only

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the cases that can be seen can be counted. It can, therefore, be concluded, due to these multiple factors, that the exact scale of those experiencing autism residing in Oman is still very much unknown.

ABA-Based Intervention for Autism in Oman The Department of Special Education was established within the Ministry of Education to oversee special education (Profanter 2009). The ministry coordinates special education programs for individuals with communication disorders, physical disabilities, intellectual disabilities, and the resultant varied spectrum of conditions stemming from such disorders. However, Profanter (2009) found that enrollment in such programs is noncompulsory and is often limited to higher functioning children with special needs and talents. There is a tendency for this special education program to group children with all types of special educational needs under one roof (Al-Adawi 2006). Therefore, Oman lacks an educational initiative, which is specifically for children with autism (Al-Farsi et al. 2011). Al-Farsi et al. (2012) explored caregivers’ perspectives on caring for a child with autism living in Oman. Specifically, caregivers were asked to give their view of the available remedial and rehabilitation services for their children with autism in the capital, Muscat. It was reported that higher income caregivers were more likely to get access to educational psychologists, occupational therapists, speech therapists, and teachers for special needs. However, although these caregivers acknowledged that they benefitted from such services, they were generally dissatisfied with overall remedial services. In Oman, having a child with special needs coupled with being financially challenged or residing in a rural area is a double disadvantage as it can exacerbate obstacles in accessing appropriate support services, if available at all (Profanter 2009). Moving forward, Mostafa (2011) states that only by investing in early intervention can improvements be made to the quality of life for people with autism often ignored by the state.

Education and Training in Oman There are currently no available courses teaching about autism or ABA explicitly for professionals in Oman. Therefore, topics on autism and best-practice guidelines are taught on psychology, psychiatry, and special education courses (Sultan Qaboos University 2014). This limits the number of Omani citizens that may wish to work in the field of ABA from becoming qualified.

State of Qatar Autism in Qatar To date, no comprehensive survey has been completed for the prevalence of autism in Qatar. A study is currently underway by Qatar Biomedical Research Institute (QBRI) with cooperation of the Cleveland Clinic and Oregon Science and Health University to find the prevalence of autism in Qatar (F. Shaban, personal communication, November 17, 2014.) The study consists of two groups, individuals with a high probability of autism and individuals with a low probability of autism. The high-probability group was comprised of children aged 5 to 12 years who were enrolled in centers for autism and were evaluated using diagnostic tools such as the ADI™-R (Rutter et al. 2003b) and the Autism Diagnostic Observation Schedule™ (ADOS™; Lord et al. 2000). This phase of the study began in 2007 and will conclude in 2017. The lowprobability group are children aged 5 to 12 years in primary school who will be screened using the Social Communication Questionnaire (SCQ; Rutter et al. 2003a). This phase of the study began in 2014 and will conclude in 2017. If the children screened show signs of autism, they will be further evaluated using diagnostic tools. In 1999, the first center for autism was established to provide services for students with developmental disabilities and autism. Currently, there are 11 centers for children with autism and other developmental disabilities in Qatar (M. Al-Attrash, personal communication, November 1, 2014). The ages of students range from birth to 21 years. Services provided include the teaching of independence and social and academic skills. Some of the centers also provide complete support services including occupational therapy, physical therapy, speech and language, counseling, medical, behavior modification, and job training and placement. In December 2007, the United Nations General Assembly unanimously passed the resolution proposed by Qatar designating April 2nd as World Autism Awareness Day (Autism Speaks 2015). ABA-Based Intervention for Autism in Qatar In 2003, members of the ABAI delegation traveled to several centers in Doha, Qatar, where they explored ways to bring behavior analysis technology and training to those centers. Three centers in Qatar currently have BCBA-supervised programs and provide training for the parents of their students. Education and Training in Qatar Qatar University (2015) offers a post-baccalaureate diploma in special education with a course in ABA. In the academic year 2007/2008, they developed a master’s degree in special

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education (MSPED), which includes an advanced ABA course. In 2012, one autism center became a BACB ACE provider, which enabled them to offer continuing education units (CEUs) to BACB certificants.

Kingdom of Saudi Arabia Autism in Saudi Arabia Sources still vary in their estimates of the prevalence of autism in Saudi Arabia. Early prevalence studies suggested lower rates compared with those found in western countries (Taha and Hussein 2014; Eldin, et al. 2008; Yazbak 2004), possibly due to underdiagnosis and underreporting of the condition in Saudi Arabia. More recent studies have noted possibly even higher prevalence rates and differences relative to male-tofemale ratios of diagnosis than in other developed countries (El-Tarras et al. 2012; Al-Ayadhi and Elamin 2013; AlZahrani 2013; Al-Salehi et al. 2009; Al-Gadani et al. 2009), although other studies report patterns more consistent with international findings (Murshid 2011). Additional diagnostic patterns have emerged relevant to autism in Saudi Arabia, including a comparative later age of diagnosis and a higher prevalence of severe communication disorders compared to locations outside the Kingdom (Hussein et al. 2011; Hussein and Taha 2013; Murshid 2011). Finally, differences in treatment availability, preference, and choice following diagnosis have emerged, with greater governmental attention to healthcare services rather than education and training and concurrent preference noted among families toward cultural or biomedical treatments for autism versus educational or behavioral treatments (Hussein et al. 2011; Al-Ayadhi and Elamin 2013; Alqahtani 2012). For those families seeking special education support within the Kingdom, public and private services are beginning to emerge; however, such services still may be difficult for families to access and obtain (Almasoud 2010, 2013; Alquraini 2011, 2013; Weber 2012). Legislation has been published which dictates eligibility and entitlement to education for children with special education needs, including autism (Alquraini 2013). Reportedly, however, there remains a gap between legislative requirements and actual practice in Saudi Arabia (Almasoud 2010; Alquraini 2011; Zeina et al. 2014; Brown 2013). Existing programs still primarily serve children with mild disabilities (Alquraini 2011; Almasoud 2013), and are primarily located in urban areas, making access for people in rural areas, where the majority of individuals with disabilities reside, difficult (Hussein and Taha 2013). Funding available for families of children with severe disabilities is far below the cost charged by the existing private organizations (Almasoud 2013; Japan International Cooperation Agency 2002).

Consequently, many children with more severe disabilities remain at risk for being underserved in private institutes or remain at home without access to treatment (Almasoud 2010; Alquraini 2011, 2013; Weber 2012). Finally, the regulations governing such services do not fully address the provision of related services, such as speech therapy, occupational therapy, or behavioral support (including ABA), resulting in the unavailability of these services for many children with autism (Alquraini 2013).

ABA-Based Intervention for Autism in Saudi Arabia Two organizations in Jeddah and Riyadh advertise ABA services provided by credentialed professionals. Other organizations have been established in Saudi Arabia to serve children with autism that offer only diagnostic or consultative services or treatment services that are non-inclusive of behavioral intervention conducted by qualified, credentialed personnel (Hussein and Taha 2013).

Education and Training in Saudi Arabia Saudi Arabia has devoted extensive resources to educational opportunities for its nationals (Fatany 2009; Taylor and Albasri 2014). Saudi Arabia invests approximately 9 billion Saudi Arabian riyals (approximately $2.4 billion) into the King Abdullah Scholarship Program, with a goal of extending educational opportunities at world-class universities for Saudi youth (Saudi-US Relations Information Service 2012). Education and psychology are listed as approved areas of study, while behavior analysis is not specifically listed as an approved major (Saudi Arabian Cultural Bureau 2014). In 2009, the first BACB ACS within Saudi Arabia was established in the special education program at Dar AlHekma University in Jeddah (Ainsleigh 2009; Kelly and AlHaddad 2014). In 2013, the Center for Autism Research (CFAR) in Riyadh announced its partnership with the University of Nevada, Reno for the purpose of offering graduate-level educational opportunities in ABA. This program will offer a master’s degree, a post-master’s certificate in ABA, and a certificate program for bachelor degree holders (Fuller 2014; CFAR 2014). Opportunities for continuing education and ongoing training in ABA also continue to increase in Saudi Arabia. Two organizations located within Saudi Arabia are BACB ACE providers and have offered continuing education in ABA since 2009. Ongoing education and training on topics related to autism treatment, including ABA, is a priority for teachers, physicians, clinicians, parents, and future researchers to further support efforts in the dissemination of ABA in Saudi Arabia.

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United Arab Emirates Autism in the United Arab Emirates The United Arab Emirates’ population consists of 87 % expatriates who avail of private education facilities, and only 13 % of the population are United Arab Emirates nationals (World Population Review 2015) who receive free public education. As specified to all schools in the Bschool for all^ initiative released in 2010 by the Ministry of Education (2015), schools are expected to accommodate all children with various educational needs and provide services that reflect international best practice. Eapen et al. (2007) conducted a review of 3-year-old children with a United Arab Emirates nationality and estimated that 29 per 10,000 children had a diagnosis of pervasive developmental disorder. This prevalence rate was comparable to that reported from other western countries at that time (Eapen et al. 2007; Elsabbagh et al. 2012). Presently, the interventions available in the United Arab Emirates for autism and related disorders include a variety of options including alternative diets, nutritional supplements, speech and language therapy, occupational therapy, medication, and ABA. There are also some culture-specific interventions being used such as Epsom salt baths and hijama (Kelly et al. 2015). Epsom salt (magnesium sulfate) baths are used in the attempt to address the reported low levels of plasma sulfate in children with autism and their decreased sulfate capacity (Adams et al. 2011). Hijama (or Al-Hijama) means cupping but, in Arabian culture, it specifically refers to wet cupping (AlBedah et al. 2011; Mayberry 2015). It involves drawing blood into a cup via a laceration of the skin (Rehman et al. 2014). Hijama is believed to alleviate pain and detoxify the body fully and is recognized as a traditional, complementary and alternative medicine by the federal and local health authorities in the United Arab Emirates (Emirates News Agency 2015). ABA-Based Intervention for Autism in the United Arab Emirates There is currently no federal policy for the licensing of ABA services or service providers. United Arab Emirates has eleven special-needs centers that implement ABA-based programs in order to serve children with autism. All of these programs have at least one on-site board certificant supervising intervention. Some of these centers also provide ABA support to children through inclusion programs in public and private schools. Education and Training There is only one BACB ACS in the United Arab Emirates, which offers a BCaBA course sequence to Emirati teachers in

training (Emirates College for Advanced Education n.d.). This college is one of two ACE organization providers on the BACB registry listed for the United Arab Emirates.

Research on Autism and ABA in the GCC In reviewing the English-language internationally published literature related to autism in Arab countries between 1992 and May 2012, Hussein and Taha (2013) found 35 articles, the majority of which came from the Kingdom of Saudi Arabia. Regarding article topics, 56.6 % of the research focused on possible etiologies of autism, with only 5.3 % investigating treatment outcomes. Hussein and Taha (2013) recommended that research policy makers prioritize autism research in the region to improve evidence-based service provision for individuals with autism. Although Hussein and Taha (2013) identified no published research articles in Bahrain between 1992 and 2012, limited research related to autism and children with behavioral difficulties does exist from this state (Al-Ansari and Ahmed 2012; Al-Ansari and Al Dakheel 2000; Almulla 2013). Only one study briefly mentioned ABA as an effective intervention (Almulla 2013) and focused on factors that hinder early diagnosis and shortage of treatment centers in Bahrain. The study highlighted the need to expand the diagnostic service capacities in Bahrain by adding to the Child and Adolescent Psychiatry department or by providing another center that provides diagnostic services by trained professionals. In his review of autism intervention in Kuwait, Ashkanani (2000) recommended that research begin with an investigation into the current prevalence in the country. Along with gaining an understanding of the scale of the problem, Ashkanani suggested that autism treatments be evaluated for effectiveness and that teachers and support workers be provided with adequate training in how to work with children with autism. Ashkanani recommended high-intensity ABA-based programs at an early age, combined with parent involvement and generalization to the outside world, as the most empirically validated method available. While autism-related studies have been published in Saudi Arabia (Al-Ayadhi and Halepoto 2011; Al-Yafee et al. 2011; Al-Zahrani 2013; El-Ansary and Ayadhi 2012; El-Hazmi et al. 1995; El-Tarras et al. 2012; Haimour and Obaidat 2013; Hussein et al. 2011; Kaya et al. 2012; Morrow et al. 2008; Murshid 2011; Zeina et al. 2014), published research examining treatment effectiveness for individuals with autism in the Kingdom, and specifically, behavioral treatment, is less prevalent. Faras et al. (2010) reviewed treatment options for people with autism, referencing intensive behavioral intervention as the most effective therapy available.

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Epidemiological studies often provide systematic information regarding the availability, quality, and accessibility of existing services (El Sabbagh et al. 2012). This brings to attention the impending and urgent need for prevalence studies in the region. ABA-based services are still in their infancy, and limited research has been conducted regarding the use of these interventions in Kuwait (Al-Hemoud and Al-Asfoor 2006). The same can be said for Oman, Qatar, and the United Arab Emirates and organization efforts are necessary to be fruitful (Eapen et al. 2007; Hussein and Taha 2013; Sartawi 1999). Building a published research base demonstrating the effectiveness of behavior analytic technologies in the GCC is also important for dissemination of the science and its availability for people who would benefit from it most (Malott et al. 2003).

Conclusion The purpose of the current paper was to provide an overview of autism and ABA-based intervention for autism in each of the GCC member states in the Middle East. A brief overview of autism, ABA-based clinical services, educational opportunities, and relevant published research was presented from Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates. A common thread throughout the region is that more research, educational opportunities, and clinical services supervised by appropriately certified behavior analysts are required as the number of individuals diagnosed with autism continues to rise. With a severe deficit in local professionals trained in ABA, the provision of ABA services is significantly restricted within all GCC states. There are currently a limited number of BACB course sequences and continuing education opportunities available across the GCC. This limits the number of GCC citizens and residents that would like to work in the field of ABA. Autism is not yet a priority in research in most Arab countries (Hussein and Taha 2013). Very little research has been conducted examining the effects of culture on autism (Samadi and McConkey 2011). However, Hussein and Taha (2013) suggest that certain factors need to be considered when reviewing autism in the Middle East such as the high rate of consanguineous marriages, high support for nuclear families by their extended families, and consequently less inclination to acquire external services. Future goals include the creation of a uniform governing body for autism and ABA-based services combining the social care, health, and education ministries in each country. Such a governing body would support the creation of policy and standards for licensing of ABA services. There needs to be a focus on evidence-based intervention for all individuals with autism and recognition of BACB certification for the licensing and practice of ABA.

Furthermore, local teachers need to have access to appropriate coursework in their university degree program that meet international standards of training and certification as well as consistent in-service professional development training opportunities to help them adequately support students with disabilities including autism. As the need for autism services increases, so will the number of organizations and professionals that offer intervention. It is important that those treatments are evaluated based on their outcomes. Researchers need to focus on providing evidence that the efficacy of ABA-based intervention for individuals with autism can be generalized to populations in the GCC and the Middle East. Comparative studies with other treatments will provide a basis for future treatment and service decisions. Professionals and specialists throughout the GCC agree that further research is needed and that government support and funding is necessary to facilitate effective care for individuals with autism in this region (Ashkanani 2000). Compliance with Ethical Standards Conflict of Interest The authors declare that they have no conflict of interest. Ethical Approval This article does not contain any studies with human participants or animals performed by any of the authors.

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