Is ABA Therapy Harmful? A Review of the Evidence

ABA

Applied Behavior Analysis (ABA) stands acknowledged as a scientifically sound and efficient method for imparting skills and addressing behavioral challenges linked to Autism Spectrum Disorder (ASD). Nonetheless, within the realm of ABA, an enduring discourse revolves around the ethical considerations of the practice. The history of ABA includes examples of intensive, repetitive intervention, overuse of punishment techniques, a focus on eliminating problematic behaviors, and forcing neurodivergent individuals to fit into a mold.

Board Certified Behavior Analysts (BCBAs) are increasingly engaging in discussions about the impact of our clinical and research methodologies on individuals and communities with Autism, recognizing those instances of harm. Consequently, many BCBAs are reassessing and adapting new practices that are more responsive to and respectful of the individuals under their care.

This article will explore the history of ABA compared to what it is today. What was most problematic regarding the practice of ABA? How has ABA changed as a result of the criticism surrounding its practice? What is the primary goal of ABA? Is ABA therapy harmful in the way it is practiced today?

Quick Primer: The History of ABA

In the early 1900s, predominant psychological theories centered on thoughts and feelings. Dr. John B. Watson, an influential psychologist, introduced behaviorism in 1913, shifting the focus from internal mental states to observable behavior. Dr. B.F. Skinner expanded on behaviorism, exploring how behavior is learned by studying antecedents (events before a behavior) and consequences (rewards or punishments following a behavior).

By the 1960s, the foundation of ABA’s teaching principles was further explored and established by various researchers. In the mid-1960s, Dr. Ivar Lovaas developed an ABA-based program to teach language to children with Autism, aiming to prevent institutionalization. Lovaas’s program, involving 40 hours of intensive, clinic-based ABA per week, demonstrated the effectiveness of ABA in teaching language and other skills. This research led to the popularization of ABA as a preferred intervention, especially in early intervention programs.

However, during this period, the application of ABA was characterized by rigidity and artificiality. Children underwent multiple, repetitive drills, and the intervention was exhaustive. The prevailing mindset, influenced by Lovaas’s methodology, fostered the belief that intervention should be highly structured, rigid, adult-driven, and, at times, aversive, involving unpleasant techniques to modify maladaptive behaviors.

Since the early 1970s, the landscape of ABA and its application has undergone significant transformations. The field has advanced through the ongoing development of new, innovative strategies. ABA has shifted towards a more naturalistic, engaging, play-oriented, and child-directed form of intervention. For example, in natural environment teaching (NET), intervention occurs seamlessly within the regular routines of daily life – during activities such as meal times, playtime, bath time, community outings, and other organic components of a child’s day. This approach contrasts markedly with the formal and clinical settings predominant in the past.

Modern-day ABA programs prioritize customization to align with the unique needs, values, and cultural background of each child and family. ABA services now emphasize choice-making and person-centered planning, allowing clients and families to actively participate in decisions regarding their target goals and treatment methods that align with their family’s culture. The synergy of professional expertise and family input is crucial in crafting the most effective program tailored to the specific needs of each child.

Criticism: ABA Therapy is Too Hard on Kids

A prevalent criticism of ABA revolves around the intensity of its interventions. Critics argue that the historically rigorous and demanding nature of ABA, often characterized by prolonged sessions featuring structured and repetitive drills, raises several noteworthy concerns. For example, it can lead to an inability to generalize skills to other settings and scenarios. When a child is exclusively taught to respond to a particular command, like “Give me the ball”, they may struggle in real-world scenarios where variations of language or requests are presented. If someone asks, “Can I have the ball please?” the child might face difficulty understanding or responding because they were not explicitly taught to recognize and react to those specific words.

Another concern is the potential for burnout, both for the child undergoing the intervention and their families, as the exhaustive schedules and relentless focus on specific behaviors may lead to fatigue and stress. Furthermore, critics contend that such intense interventions may inadvertently overshadow the broader developmental needs of the child, particularly in the realms of social and emotional growth.

These situations underscore the importance of incorporating generalization and play into behavioral interventions. Modern-day ABA has adjusted its approach to include generalization, which involves teaching individuals to apply their learned skills across different situations, settings, and stimuli. ABA now encourages flexibility and adaptability to various scenarios, ensuring that skills acquired in structured settings can be effectively applied in the diverse and dynamic situations encountered in everyday life.

In addition, ABA has moved away from the traditional format of sitting behind a desk, toward more play-based methodologies. Sara Germansky, a BCBA, provides an illustrative example: “I might set up something where we’re playing with cars, and if I’m working on learning colors with a kid, I might have two cars in front of me – one that’s red and one that’s yellow.” The child may ask for a car, which would result in Germansky saying “Do you want the yellow one or the red one”. The child may then say “I want the red car.” Germansky would then say “Which one is red?’ In this play-based scenario, the child is prompted to express preferences, expand language skills, and learn colors in a more naturalistic setting.

More importantly, ABA is rarely implemented 40 hours a week as initially recommended by Dr. Lovaas.
– Jaymie Hodara – BCBA
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Most children currently receive 10 to 20 hours per week, with more severe cases or significant delays requiring more hours, and therapists conducting ABA are trained to be animated and fun. This move towards less intensive and more individualized approaches aims to enhance the naturalistic learning experience and foster the generalization of acquired skills beyond therapy sessions. But is it still effective?

Mece and Sherifi (2022) concluded a study where the effectiveness of an ABA intervention for a two-year-old boy was tracked over three years. The play-based intervention was implemented for 4.5 hours per week and was designed to address interaction and engagement with peers, imitation of actions and sounds, and increased communication and language skills. The results indicated that the child made significant improvements in cognitive, language, and social skills thus indicating that modern-day ABA is still an effective form of treatment for Autism.

Criticism: Too Focused on “What Kids Shouldn’t Do”

Is ABA therapy harmful

ABA has also faced criticism for its notable emphasis on behavior reduction and elimination. A core tenet of traditional ABA approaches involves identifying and modifying behaviors deemed undesirable, often through techniques like reinforcement and punishment. Critics argue that this focus on eliminating behaviors may sometimes overshadow a more comprehensive understanding of the underlying causes or communicative functions of these behaviors. Concern is expressed that an exclusive concentration on behavior reduction might not adequately consider the individual’s unique needs and could neglect the potential communication aspects of certain behaviors.

For example, Dr. Ronit Molko, a BCBA-D, worked with a non-verbal child with Autism who used an array of different grunting sounds to communicate his needs. His mother grew to understand what each sound meant and was able to respond appropriately to his requests. In this case, a traditional BCBA would propose to use ABA to diminish this specific behavior. However, the child’s mother disagreed and asserted that these noises constituted the child’s form of communication. To her, those vocalizations hold significance as a unique and essential means of expression. This scenario highlights a key point of contention within the application of ABA, where the definition of what constitutes meaningful communication, and the appropriate focus of behavioral interventions may vary among individuals and their caregivers.

Critics of ABA have also raised concerns about attempts to completely eradicate stimming behaviors (flapping, clapping, waving, or any other repetitive movement or vocal sound), emphasizing the importance of understanding and respecting the sensory and self-regulatory functions these behaviors may serve. However, as the field evolves, there is a growing recognition that interventions should be person-centered, respecting the individual’s unique needs and preferences.

Modern ABA practitioners aim to address a broad range of skills beyond behavior reduction, encompassing language development, social skills, and adaptive behaviors seeking to create a positive and inclusive therapeutic environment. Open communication between parents and therapists is crucial to ensuring that the therapy aligns with the values and preferences of the family, fostering a supportive and comfortable environment for the child.

Imagine a child with Autism who exhibits challenging behaviors like tantrums when faced with transitions. The modern-day ABA therapist, recognizing the need for behavior change, structures sessions to address these challenges by incorporating play and engagement. During transitions, the therapist would use visual schedules and provide positive reinforcement when the child successfully navigates the change without a tantrum. The atmosphere is kept light, and the child’s interests are considered when selecting the activities, making the learning experience enjoyable.

ABA practitioners now work with families, to select clear and measurable goals for behavior change. Key aspects in reaching those goals involve positive reinforcement and teaching replacement behaviors, which fulfill the same function as the problem behavior but allow for a more adaptive way for the individual to meet their needs. Delprato (2001) found that these modern-day, naturalistic approaches to ABA were more effective than traditional ABA methods in building skills such as language and communication.

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Criticism: ABA Tries to Make Neurodiverse Kids “Like Everyone Else”

The criticism that ABA therapy doesn’t adequately respect neurodiversity and aims to make children with Autism conform to the mold of “normal” children is the perspective expressed by some critics. It reflects concerns about the historical rigidity of ABA interventions, which were at times perceived as overly focused on normalization rather than appreciating and embracing the diverse ways individuals with ASD experience the world.

ABA was initially conceived with a model suggesting there was an ideal way to be, and ABA will help you conform to that ideal. However, in application, ABA primarily centers on addressing behaviors that hold social significance, specifically those that influence the safety and learning experiences of your child.

It is crucial to clarify that ABA is not about force or control. Instead, its purpose is to teach children with Autism the skills necessary for effective communication and to enable them to participate in activities typical for their peers. The overarching goal of ABA is never to erase someone’s identity or diminish their value based on a label or disorder.

Contemporary ABA focuses on teaching functional and appropriate alternatives to challenging behavior. It emphasizes promoting a child’s independence while respecting their neurodiversity. Unlike past approaches that sought to eliminate every behavior associated with Autism, modern ABA concentrates on identifying and managing behaviors that interfere with daily life. For example, while stim behaviors may present social acceptance challenges, ABA acknowledges its purpose for children with Autism, who may use stim behaviors to manage energy and self-regulate.

As a BCBA, many parents of newly diagnosed children have asked me to eliminate stim behaviors such as body stiffening or hand flapping. As a response, I urge these parents to look at the times the child engages in these behaviors, which mostly occur when they are excited or experiencing some other heightened emotion. I compare the use of these behaviors to actions we engage in when we feel nervous such as leg shaking or finger/hand rubbing. This allows parents to realize and consider the function of the stim behaviors, and consequently do not want them eliminated.

The primary objective of ABA therapy is for the child to acquire valuable skills for behavior management through activities that motivate them. In employing a variety of situation-specific techniques, ABA uses antecedents (events before a behavior) and consequences (events after a behavior) to understand the triggers and maintainers of a child’s behavior. This approach involves identifying patterns and understanding the purpose a behavior serves for the child. The therapist can then choose, teach, and reinforce an appropriate replacement behavior that fulfills the same needs of the child.

A BCBA, Juliet Barnett (2022), worked with a young student with Autism who struggled with expressing his needs appropriately. He often resorted to yelling to get an adult’s attention. Through observations and preference assessments, she determined the child’s fondness for Legos and incorporated them into communication skill-building activities. During play, Barnett strategically placed Lego pieces out of reach, encouraging the child to ask for assistance. Positive reinforcement, such as giving a Lego when the child made an appropriate request was consistently applied. Barnett modeled the desired language, reinforced the child’s attempts, and gradually advanced toward the target goals. The therapy simultaneously addressed multiple skills, like naming colors during Lego play.

The emphasis lies on positive social interactions and child-led learning, aligning teaching opportunities with the child’s preferences to maintain motivation and engagement.

Isn’t Discrete Trial Training Bad? (DTT)

An ABA therapy session

Discrete Trial Training (DTT) emerged in the 1980s through the pioneering work of Dr. Lovaas as a crucial component of the Lovaas Method, within the realm of ABA therapy for Autism. DTT involves breaking down complex skills into manageable components, employing the ABCs of ABA: Antecedent-Behavior-Consequence. It functions by presenting a specific instruction or cue (antecedent), the individual responds (behavior), and then receives feedback (consequence).

Regrettably, the initial implementation of DTT in ABA drew criticism due to Dr. Lovaas incorporating aversive reinforcement methods such as yelling and electric shocks. However, these practices were swiftly replaced with positive reinforcement such as treats, toys, or engaging activities.

Despite its well-documented effectiveness in treating Autism and contributing to ABA’s acclaim, DTT continues to face substantial criticism for its perceived drawbacks. It is argued that the approach is overly repetitive and exhaustive, potentially leading to rote learning that lacks generalizability to diverse settings.

However, DTT remains a valuable tool in modern ABA practices. It is primarily used to teach language skills to children with Autism. DTT provides a clear structure using a predictable framework for learning. The reinforcement at the end of a task and the short task interval encourage the child to pay attention during the task. As an individualized learning tool, DTT can take place in various settings such as home, school, or outdoors.

DTT proves to be a powerful method for breaking down intricate learning tasks into manageable segments. Successful trials not only enhance a child’s confidence but also ignite enthusiasm for acquiring new skills. It is typically used in conjunction with naturalistic or incidental teaching approaches to promote the generalization of skills to real-life settings.

In a study conducted by Jenet et al. (2008), a comparison was made between DTT and an alternative technique for teaching children to express their needs. The results revealed that both techniques were successful in imparting the skill of requesting, but DTT demonstrated an accelerated learning curve, with the child acquiring the skill sooner due to repeated trials in a short period. Furthermore, parents observed a high level of generalization at home for children who underwent DTT.

What Does ABA Therapy Actually Aim At?

At its core, ABA therapy aims to enhance the lives of individuals, particularly children, by fostering positive behavioral changes and acquiring essential life skills. Through ABA, children can develop improved communication, social interaction, self-help, and academic skills. The therapy focuses on breaking down complex tasks into manageable components, allowing for systematic and tailored learning. By reinforcing positive behaviors and addressing challenging ones while teaching replacement behaviors, ABA helps children build confidence, resilience, and adaptive strategies. The ultimate goal is to empower children to lead more fulfilling and rewarding lives by equipping them with the tools to navigate social interactions, communicate effectively, and engage meaningfully in various activities.

The shift towards a more compassionate and ethical ABA involves incorporating a person-centered perspective, acknowledging the autonomy of clients, and actively engaging in ongoing self-reflection. BCBAs are at the forefront of championing these changes, fostering an ABA that is not only scientifically rigorous but also respectful, inclusive, and responsive to the diverse needs of the individuals they serve. The evolution of ABA reflects a commitment to ethical principles, ensuring the behavior analysis aligns with the highest standards of care and respect for individual dignity.

References

Barnett, J. (2022). Serving students with Autism: Ensuring a place for applied behavior analysis. Kappan, Vol. 103, No. 6, pp. 27-31.

Lord, C. Child Mind Institute. (2023). The controversy around ABA. Child Mind Institute. Found on: https://childmind.org/article/controversy-around-applied-behavior-analysis/.

Council of Autism Service Providers. (2020). Applied behavior analysis treatment of autism spectrum disorder: Practice guidelines for healthcare funders and managers (2nd ed.) Found at: https://www.casproviders.org/asd-guidelines.

Dawson, G., Jones, E.J., Merkle, K., Venema, K., Lowy, R., Faja, S., . . . & Webb, S.J. (2012). Early behavioral intervention is associated with normalized brain activity in young children with autism. Journal of American Academy of Child Adolescent Psychiatry, 51 (11), 1150-1159.

Decker, J.R. (2017). 25 years of litigation trends: Applied Behavior Analysis (ABA) lawsuits involving students with autism. Paper presented at the annual meeting of American Educational Research Association, San Antonio, TX.

Delprato, D. J. (2001). Comparisons of Discrete-Trial and Normalized Behavioral Language Intervention for Young Children with Autism. Journal of Autism & Developmental Disorders, 31(3), 315-325.

Dillenburger, K., Keenan, M., Doherty, A., Byrne, T., & Gallagher, S. (2010). Living with children diagnosed with autistic spectrum disorder: Parental and professional views. British Journal of Special Education, 37 (1), 13-23.

Eapen, V., Črnčec, R., & Walter, A. (2013). Clinical outcomes of an early intervention program for preschool children with autism spectrum disorder in a community group setting. BMC Pediatrics, 13 (3), 1-9.

Fein, D., Barton, M., Egsti, I.M., Kelly, E., Naigles, L., Schultz, R.T., . . .  & Tyson, K. (2013). Optimal outcome in individuals with a history of autism. Journal of Child Psychology and Psychiatry, 54 (2), 195–205.

Jennett, H. K., Harris, S. L., & Delmonlino, L. (2008). Discrete trial instruction vs. mand training for teaching children with autism to make requests. The Analysis of Verbal Behavior, 24, 69-85.

Hart, J.E. & Whalon, K.J. (2008). 20 ways to promote academic engagement and communication of students with autism spectrum disorder in inclusive settings. Intervention of School and Clinic, 44 (2), 116-120.

Molko, R. (2021, May 11). Understanding the evolution of ABA. LEARN Behavior.

Simpson, R.L. (2001). ABA and students with autism spectrum disorders: Issues and considerations for effective practice. Focus on Autism and Other Developmental Disabilities, 16 (2), 68-71.

Virués-Ortega, J. (2010). Applied behavior analytic intervention for autism in early childhood: Meta-analysis, meta-regression and dose-response meta-analysis of multiple outcomes. Clinical Psychology Review, 30 (4), 387–399.

Vuran, S., & Unlu, E. (2012). Case study: Training a mother of a child with Autism on how to provide discrete trial teaching. International Journal of Early Childhood Special Education. 4(2), 95-103.

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