ABA Therapy vs CBT for Autism: Which is Better?

Applied Behavior Analysis (ABA) and Cognitive Behavioral Therapy (CBT) are both evidence-based best practice treatments for Autism. While there is some overlap in their approaches there are key differences. ABA focuses on analyzing and determining the function of behavior and uses positive strategies to address specific and immediate behavior issues and to teach socially significant skills. CBT is centered on the notion that thoughts and feelings impact our emotions and actions. Consequently, by changing your thoughts you can change your actions. This article aims to differentiate between ABA therapy vs CBT, to help you decide which treatment approach is more beneficial for your child with Autism.

What is ABA Therapy for Autism?

ABA is a treatment method that is primarily used for addressing challenges related to developmental disorders such as Autism. It is an individualized, evidence-based, and data-driven approach that focuses on observable and measurable behaviors and the environmental elements that influence them. According to the principles of ABA, which are grounded in learning theory, behavior is influenced by its consequences. Behavior analysts can produce positive behavioral change by systematically analyzing and modifying these consequences.  

Seven dimensions of ABA determine the strategies used within a treatment program. The dimensions are as follows:

• ABA therapists ensure that the skills learned are generalizable to novel settings and can be utilized in creative ways.
  
• ABA aims to provide effective services, which means data must be collected to show the impact of the treatment.
  
• Intervention plans must be understandable and free of jargon so that they can be implemented by all stakeholders.
  
• The plans should be based on scientific research, data, and objective information.
  
• ABA therapists address socially significant behaviors. Family members should collaborate with the ABA team to ensure that the behaviors being addressed are meaningful and relevant to the client.
  
• It is important for these behaviors to be observable and measurable. This ensures the same behavior is being addressed by therapists and family members.
  
• Lastly, the dimensions of ABA require the implementation of research-based techniques and teaching methods.

The ultimate goal of ABA is to increase behaviors that are helpful and decrease behaviors that are harmful or impact daily living. Its intervention can target various skills such as self-care skills, attention span, academic skills, social skills, play skills, language skills, community involvement, safety skills, aggression, and self-injury.

What is Cognitive Behavioral Therapy for Autism?

CBT is an evidence-based, collaborative, and structured talk therapy that teaches techniques for managing emotions, communicating, conflict resolution, and coping with stress and anxiety. This form of talk therapy focuses on the connection between thoughts, feelings, and behaviors. According to the principles of CBT, behavior is not determined by the environment but by the interpretation of the environment. Negative, unrealistic thoughts about a situation can produce challenging or inappropriate behavioral responses to that situation.

It evolved from ABA with the addition of cognitive theory which takes mental processes such as thoughts and feelings into consideration. Aaron Beck, known as the founding father of CBT, identified three levels of cognition:

1. Core beliefs are learned from early childhood experiences and define negative views of oneself, the world, and the future.
   
2. Dysfunctional assumptions which are a result of focusing on negative aspects of a situation.
   
3. Automatic negative thoughts are involuntary, negative perceptions of the environment that occur so frequently that they become a habit.

CBT focuses on identifying negative thought patterns and false beliefs, testing the narratives, and then restructuring them to lead to more positive behavioral outcomes. Essentially, the goal of CBT is to change behavior by changing thoughts and feelings.

ABA Therapy vs CBT Methodologies

CBT and ABA have distinct differences in their scope and application. CBT is an effective tool for treating Autism’s typically co-occurring conditions such as anxiety, depression, or oppositional defiance disorder (ODD). CBT can be conducted in a group or with individual sessions. Most patients begin receiving CBT after the age of 7 or within their teen years. It is a short-term, goal-oriented approach that consists of anywhere between 6 and 14 weekly sessions lasting 30 to 60 minutes.

Instead of focusing on changing overt behaviors, CBT uses a variety of strategies to change negative thought patterns and feelings about a given situation. CBT encourages the child to be more aware of their internal state, thought processes, and behavioral patterns. It first teaches the child to identify and acknowledge their thoughts and feelings. Then, when they are aware of these patterns, they are taught to replace them through the use of various coping mechanisms.

Some techniques used in CBT include:

1. Cognitive restructuring which involves identifying and reframing negative thought patterns into more positive and productive thought patterns. It aims to show that not every thought or emotion is true.
   
2. Guided discovery asks questions to challenge the client’s thoughts and belief system. This typically leads to seeing situations from a different perspective.
   
3. Exposure therapy which gradually exposes the person to situations or activities that create fear or anxiety.
   
4. Relaxation techniques like deep breathing, visualization, and muscle relaxation.
   
5. Journaling helps clients recognize their thoughts and feelings by putting them down on paper.
   
6. Activity scheduling where all the tasks needed to be completed are written down and ordered from a lower level of anxiety.
   
7. Role-playing can also help clients see alternative perspectives.

On the other hand, ABA is widely used to specifically address behavioral challenges associated with developmental disorders such as Autism. Children with Autism typically begin ABA between the ages of 2 and 6 years old, often requiring between 20 to 40 hours of intensive 1:1 therapy each week. In addition, it can take up to 3 years of consistent services for positive results to be noticed.

ABA therapy involves three steps. The first is the identification and definition of target behaviors. Target behaviors should be socially significant and are immediately necessary for the child’s long-lasting success. The process of selecting a target behavior includes caregiver interviews, checklists, or direct observations. Once the target behavior is selected it is operationally defined in observable and measurable terms.

The second step is the methodical implementation of techniques, such as;

1. Reinforcement which is a consequence that increases the future frequency of a behavior such as offering praise to a child who successfully dressed independently.
   
2. Prompting which consists of things such as touches, demonstrations, and instructions that are designed to increase the likelihood of a correct response. For example, pointing to the next article of clothing the child should put on while getting dressed.
   
3. Shaping which is reinforcing closer and closer approximations to the desired behavior. For example, when teaching a child to say apple you reinforce “ah” then “ap” then “apple”.
   
4. Modeling involves demonstrating the desired behavior which can be done in-person or through the use of videos.

These techniques are used to teach adaptive behaviors that serve the same function or purpose for the child as challenging behavior. For example, a child who consistently talks out of turn in class will be taught to raise their hand and wait to be selected to speak.

The last step in ABA methodology is the continuous measurement and evaluation of the process. Throughout the intervention, data is collected and analyzed to ensure the treatment plan is effective and meaningful change is being produced.

While CBT and ABA have different practices, techniques, and applications, they share the same ultimate goal of increasing the client’s ability to cope in any environment by building the necessary skills.

ABA vs CBT Effectiveness

Both CBT and ABA are evidence-based practices that have been studied rigorously through numerous randomized controlled trials and systematic reviews. This means their techniques and strategies have a solid foundation in research that proves they can be effective for children with Autism. There is more evidence of the effectiveness of ABA due to its extensive application in educational and clinical settings. ABA was also specifically designed to treat behavioral disorders such as Autism.

The pivotal study in ABA was conducted by Lovaas (1987) which showed children who received 40 weekly hours of ABA were more likely to attain average cognitive functioning compared to their peers. This study was followed up by McEachin in 1993 to show that the participants preserved the gains made in the Lovaas study. In addition, the study has been replicated numerous times with similar results. Dawson (2011) reviewed 27 peer-reviewed studies that showed behavioral interventions were effective at improving language, cognitive abilities, adaptive behavior, and social skills, and reducing anxiety and aggression in children and teens with Autism.

On the other hand, CBT is adaptable for various mental health concerns for children with Autism. Weston, Hodgkins, and Langdon (2016) performed a meta-analysis of 48 studies where CBT was conducted with Autistic children that showed it was effective. It was discovered that 70% of participants responded positively to treatment, which is consistent with the expected response for the neurotypical population.

A limitation of CBT noted by Sharma et al. (2014) and Spain et al. (2015) is that there is a need to increase the number of CBT sessions. This would mean an Autistic child would receive as much as twice the number of recommended sessions for a neurotypical child. Some children with Autism can suffer from impaired Theory of Mind abilities which can result in false assumptions about the intentions and emotional states of others. Therefore, more sessions are required to overcome this hurdle.

Comparing the effectiveness of CBT and ABA can be difficult because they target different aspects of functioning. As described earlier, CBT addresses conditions that occur alongside Autism such as anxiety, or emotional regulation, while ABA addresses specific behavioral challenges that are associated with developmental disorders.

Ethical Considerations

Despite its proven effectiveness, ABA has been surrounded by controversy. It is heavily criticized for being too harsh and too focused on what children should not do. For example, ABA was designed by Lovaas to be implemented for 40 to 45 hours a week in a clinical setting. In addition, ABA has been accused of trying to make children appear typical or “like their peers” rather than acknowledging and accepting their unique differences.

However, ABA has evolved to include more generalization of skills, and less intensive hours, to occur in more natural settings and home environments, and behavior therapists only address challenging behaviors that impact a child’s daily living. Now, ABA focuses on promoting a child’s independence while respecting their neurodiversity.

Unlike ABA, CBT is seen as less intensive because it involves active participation and practice of the strategies outside of the clinical setting. Nonetheless, CBT has also faced criticism regarding its use for children with Autism. Certain individuals with Autism face challenges related to interoception, which involves difficulty understanding and recognizing their thoughts and emotions. Successfully altering thought patterns and emotions through CBT necessitates the initial ability to identify and comprehend them.

In addition, CBT requires robust language skills and abstract thinking abilities, presenting a potential challenge for children with Autism. To address these hurdles, therapists have devised strategies to incorporate modifications that ensure the relevance of CBT techniques for Autistic children and have increased the number of sessions required for successful treatment.

Who is Each Therapy For?

CBT is most effective for children who are at least 7 years old and have less severe symptoms of Autism or Level 1 Autism. This form of talk therapy requires participants to have robust language skills and the ability to think abstractly. CBT is worth exploring if your child has difficulty with stress anxiety or other emotional issues, if your child has specific fears or dread certain social situations, if your child has rigid, negative thought patterns, or if your child needs help understanding and navigating social situations.

There are no prerequisite skills needed to enter ABA programs. These programs are most effective when begun before the age of 3 and are better suited for kids with more severe deficits or Level 3 Autism. If your child is nonverbal, has specific challenging behaviors such as self-injurious behavior or aggression, or significantly impaired play or social skills then ABA should be considered as a treatment option.

Collaboration Between ABA Therapy and CBT?

Implementing an ABA program while conducting CBT with a child can provide a more individualized and holistic treatment plan for children with Autism. By utilizing ABA’s focus on behavior modification and CBT’s concentration on cognitive processes, therapists can create a more comprehensive treatment plan to address a wider range of challenges. This type of approach recognizes that thoughts, emotions, and behaviors are all interconnected and aims to target these areas concurrently for the best possible outcome. For example, an ABA program can be implemented to teach a child to request a break instead of screaming and throwing chairs, while simultaneously, CBT will help the child to identify and understand the emotions that lead to screaming and chair-throwing. This combined approach not only teaches a child how to ask for a break but also when to ask for a break.

Summary

Both CBT and ABA are effective, evidence-based treatment approaches for Autism. However, they differ in their scope and implementation. CBT focuses on the effects of thoughts and feelings on behavior, while ABA focuses on the effects of the environment on behavior. CBT is best suited for higher-functioning children with strong language skills, and ABA is most beneficial for severe, nonverbal children with Autism. The needs of children with Autism are unique and the approach selected should be based on those individual needs, with collaboration and open communication being at the forefront of any decision.

References

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Danial, J. T., & Wood, J. J. (2013). Cognitive behavioral therapy for children with autism: Review and considerations for future research. Journal of Developmental and Behavioral Pediatrics, 34(9), 702–715. Retrieved August 17, 2016, from http://www.ncbi.nlm.nih.gov/pubmed/23917373

Dawson G., “Behavioral interventions in children and adolescents with autism spectrum disorder: a review of recent findings.” Current Opinion in Pediatrics, 2011; Vol 23: pp 616–620

Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses. Cognitive Therapy and Research, 36(5), 427–440.

Lang, R., Regester, A., Lauderdale, S., Ashbaugh, K., & Haring, A. (2010). Treatment of anxiety in autism spectrum disorders using cognitive behavior therapy: A systematic review. Developmental Neurorehabilitation, 13(1), 53–63.

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Lovaas O. “Behavioral Treatment and Normal Educational and Intellectual Functioning in Young Autistic Children.” Journal of Consulting and Clinical Psychology, 1987; Vol. 55, No. 1: pp3-9

McEachin J, et al. “Long-Term Outcome for Children With Autism Who Receive Early Intensive Behavioral Treatment.” American Journal on Mental Retardation, 1993; Vol. 97, No. 4: pp 359-372

Sharma, S., Woolfson, L. M., & Hunter, S. C. (2013). Maladaptive cognitive appraisals in children with high-functioning autism: Associations with fear, anxiety and theory of mind. Autism. https://doi.org/10.1177/1362361312472556

Spain et al. (2015). Cognitive Behavior Therapy for adults with autism spectrum disorders and psychiatric co-morbidity. Research in Autism Spectrum Disorders. Vol. 9: pp 151-162.

Weston L, Hodgekins J, Langdon PE. Effectiveness of cognitive behavioral therapy with people who have autistic spectrum disorders: A systematic review and meta-analysis. Clin Psychol Rev. 2016 Nov;49:41-54. doi: 10.1016/j.cpr.2016.08.001. Epub 2016 Aug 4. PMID: 27592496.