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Applied behavior analysis

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ABA (Applied Behavior Analysis) is a controversial therapy that uses a aversion and/or reward system on autistic children: a desired behaviour is rewarded, while the disapproved behaviour is punished.[1] Some ABA therapists refuse to participate the aversion side of ABA, instead focusing on reward and praise to improve the behavior of autistic children.[2]

Critics of ABA have voiced concerns that it is too controlling, and that it is often excessively harsh in practice. There are concerns about it being linked to PTSD.

It is described by proponents as "the application of principles derived from learning theory and the experimental analysis of behavior to issues of social significance."[3] This does not much reflect how it's done in practice. In any case, the state of ABA therapy has somewhat improved since the early days, since the aversive aspects are being phased out by some practitioners.[2]

How it works[edit]

For up to 40 hours a week, a therapist trains an autistic person (usually a child) to do certain tasks. Desired behavior or a correct answer is rewarded with praise, a small piece of food, a sticker, tickles, or a token that can be exchanged for a reward (like a break from therapy or access to a favorite toy). Undesired behavior or a wrong answer may be ignored, or it may be punished with harsh words, the loss of a token or prize, or an "aversive" (e.g. vinegar in the mouth, forced inhalation of ammonia, or an electric shock).[4][5]

Discrete trials may be used to teach and assess learning. The child may be told to touch the correct picture card (e.g. "touch cat"). The therapist gathers careful data about the number of correct answers. If the child gets the wrong answer, hand-over-hand may be used to make the child touch the correct answer.

The ABA industry involves over $17 billion annually in the US.[6]

Benefits[edit]

Some claim this can hypothetically be beneficial in removing harmful behaviors like self-harming, and in encouraging learning through positive reinforcement.[7] A scientific review has stated that this therapy is effective for improving intelligence scores, academic performance, and adaptive behavior in young children on the autism spectrum but also states the evidence strength is low.[8]

Evidence?[edit]

However, several literature reviews have described the evidence base as weak.[9][10] While ABA has been referred to as the "gold standard," other treatments have been shown to have similar effectiveness.[11]

Similar techniques produce results that are far from robust. Early Intensive Behavioral Intervention (EIBI) has only weak support for its efficacy,[12] and Positive Behavior Support has been found to be ineffective.[13]

There are also concerns that putting a child in ABA and nothing else may result in them missing out on other opportunities, such as speech and language services,[14] play groups, or just free time to spend playing and enjoying childhood.

Historically, the field has been relatively isolated from other branches of psychology, with behaviorists repeatedly citing each other instead of drawing from outside sources.[15]

Evidence is also seemed to be lacking for other conventional therapies for autism. However, the results are promising.[8] However this is NOT an excuse to try alternative medicine for autism (such as biomedical treatments) as that probably will not work and probably harm the child.

Remember: the conventional therapists actually have evidence of actual benefit.

The bad side[edit]

Examples of punishments and rewards.
I’ve seen people call ABA “dog training for children.” When I see that, I tend to go on Twitter rants in reply to it, because from everything I have read and seen of ABA, it is NOT “dog training” for children. …I would never treat a dog that way.
—Carol Millman, professional dog trainer[16]

ABA has been heavily criticized for a lack of ethics.[17] Researchers have begun discussing the ethical issues and serious side effects related to intensive behavior modification.[18][6] The way autistic children are treated in ABA has been compared to the treatment of orcas at SeaWorld.[19]

Education specialists are beginning to realize that punishment isn't always effective.[20] "Eventually there's this whole population of kids we refer to as overcorrected, overdirected, and overpunished. Anyone who works with kids who are behaviorally challenging knows these kids: They’ve habituated to punishment," says psychologist Ross Greene.[21] Instead of trying to control the child, adults should talk to children and help teach them self-control.

A history of evil[edit]

You see, that is one of the reasons that people stay away from the use of punishment — they don't want to commit themselves. After you hit a kid you can't just get up and leave him; you are hooked to that kid.
—Ole Ivar Lovaas[22]

Ole Ivar Lovaas popularized ABA.[23] His work involved screaming in children's faces, hitting them, and administering painful electric shocks.[24] The goal was to make them obedient and train them to act normal.

Lovaas believed that in order for it to work, the child's life needed to be controlled "during all or most of the child's waking hours."[25]

Lovaas also used such techniques for the Feminine Boy Project - an early attempt at reparative therapy for homosexuality - at UCLA in 1974.[26]. The experiment was met with major criticism from within it a few years later.[27] [28] But experiments continued, with one of the "success stories" ending in suicide.[29] Psychiatry has some dark roots.

And the torture still exists today. *Cough* Aversive therapy.[30] *Cough* Judge Rotenberg Educational Center using electric shock therapy.[31] Aversion therapy is considered unethical to use on autistic children.[32]

"Chemotherapy for autism"[edit]

Some ABA proponents claim that autism is like cancer and ABA is like chemotherapy.[33][34] This is ignoring the facts that

  1. autism isn't fatal,[citation NOT needed]
  2. autism can't be "cured,"
  3. there are other therapies and approaches for autism,
  4. doctors don't profit from chemotherapy the same way ABA agencies profit from giving ABA,[35] and
  5. cancer survivors aren't criticizing chemotherapy en masse the way autistics are criticizing ABA.

Some people do seem to seriously believe it is the cure to autism.[36] This ABA cure thing is absolute pseudoscience. Some parents seem to take too far with 40+ hours therapy per week and forcing their children on the spectrum to act completely normal — which many autism acceptance activists argue is cruel.[37] They claim that things like harmless stims are in fact beneficial to the child as it provides comfort. Canadian based researcher and activist Michelle Dawson has worked hard to have ABA banned as an autism treatment and has written in detail about its pitfalls.[38]

Lack of understanding[edit]

ABA neglects current research and data on children with Autism and does not attempt to understand it.
—Sandoval-Norton and Shkedy (2019)[6]

An ABA therapist may have a very poor understanding of what autism is and why autistic people do the things that they do. No training on autism is required.[39]

Treating the behavior also means risking completely misunderstanding the reason for the behavior. For example, a kid who cries during lunch could have a number of reasons for doing this: the food is horrifyingly disgusting to their hypersensitive system, they're tired, they're upset because what comes next in the routine is something that scares them, they remember getting yelled at during lunch yesterday for not sitting still enough, et cetera.[40][41] By trying to stop the behavior instead of figuring out what's wrong, you could be forcing the kid to put up with something awful.

Same method, same failures[edit]

An ABA therapist may not adapt their teaching methods even when the person is obviously not learning. Instead, the person may be pushed through drill after drill, being asked to do things they don't understand, regardless of how frustrated they become.

Educator Leanna Carollo explained that when she started ABA, she worked with a young man trying to teach him "over" and "under." He didn't understand the difference and had been going through the same lesson, again and again and again, for 2 months. Instead of trying to teach using different methods or integrate his efforts, the therapists gave up and moved on to a different lesson. Students would have outbursts of frustration after being asked over and over to do tasks they did not understand. It was only when Carollo started to stray from her ABA training and use a non-ABA approach (which involved showing empathy, incorporating students' interests, and encouraging self-advocacy) that it began to feel less like torture and more like something actually helpful.[42]

Ignoring medical reasons for behavior[edit]

Some autistic people have apraxia, a condition which makes it hard for them to move their body parts (e.g. hands) the way they want to.[43][notes 1] During ABA drills, an autistic person may be asked to demonstrate intelligence through commands like "touch red" or "touch cat" with cards in front of them. If the person has serious apraxia, they may be unable to touch the correct card, even though they know what it is.[44] Thus, they may be assumed to be unintelligent when they are not.

There are even stories of BCBAs treating a medical condition as a "behavior" to correct. One therapist explained that a person who is medically incapable of being toilet trained would be forced to use the bathroom every 10 minutes. After 7 months of no learning, the person's skin became raw and irritated from being wiped so often; they would cry, avoid the painful wiping, and injure themselves in distress. Yet the therapist discussing the issue was reluctant to report the physical abuse.[45] It is not known whether the person is still enduring this today.

Serious overreach[edit]

When I was six years old, people who were much bigger than me with loud echoing voices held my hands down in textures that hurt worse than my broken wrist while I cried and begged and pleaded and screamed.
—Julia Bascom[46]
I tried everything I could to see if there was a way I could do ABA without running into ethical issues, but I repeatedly found that I had to make a choice between doing the ABA and respecting the child.
—"Steph," an ex-therapist[47]

The "behaviors" that ABA targets can be anything the therapist chooses. An autistic person may be expected to stop playing,[48] make eye contact (which is frightening or painful to some autistic people[49][50]), sit perfectly still,[51] act like nothing is wrong when they feel tired or overwhelmed or desperate for a break,[52] hug on command, or stop making calming repetitive movements.[6]

And they can't just ignore it when a therapist demands something unreasonable. Not when the therapist is constantly getting in their face.[53] Not when ABA is supposed to happen for 40 hours per week.[52] Not when pleasing the therapist might be the only way to get food or their teddy bear. Not when the therapist might use physical force.[54][55]

And then there is the question of ABA therapists reporting parents for child abuse just for taking their autistic kids out of ABA therapy.[56]

Side effects[edit]

Compliance, learned helplessness, food/reward-obsessed, magnified vulnerabilities to sexual and physical abuse, low self-esteem, decreased intrinsic motivation, robbed confidence, inhibited interpersonal skills, isolation, anxiety, suppressed autonomy, prompt dependency, adult reliance, etc., continue to be created in a marginalized population who are unable to defend themselves.
—Sandoval-Norton and Shkedy (2019)[6]
Preliminary research suggests that ABA greatly increases the risk of PTSD in a population that is already vulnerable.

Research into the long-term effects of ABA is minimal,[6] so the exact side effects may still be unclear.

One study found that autistic people who were exposed to ABA are much more likely to show signs of Post-Traumatic Stress Disorder,[57] though the study's methodological quality has been heavily criticised by behaviour analysts.[58] Further investigation has not yet been conducted.

Excessive compliance[edit]

Compliance is correlated with denial, disengagement, and low self-esteem.[59] Overuse of external reinforcement may lead to decreased intrinsic motivation.[60][61] Research warns that autistic adults show signs of prompt dependency and low motivation.[62] Learned helplessness may also be involved, and the presence of an aide tends to inhibit social interaction in children with disabilities.[63]

Yet self-advocacy is one of the most important skills for an adult, especially an autistic adult.[64] Teaching them to be obedient might make life easier for the parent in the short term, but it won't help the child live a better life as an adult.

Then there are the horrifying implications of teaching a child that they must always allow adults to do whatever they want to their body...

Aggression[edit]

People worry a lot about their "violent" Autistic children as they get bigger and stronger and harder to control. But far too often, the "violence" is stirred up by years of very frustrating therapy…. There's only so long that a person can take being pushed into sobbing meltdowns of frustration before they are willing to do whatever it takes to get the torment to stop.
—Maxfield Sparrow, an autistic adult who underwent ABA-style therapy[65]
About six months after the therapy started, Jennifer said Adam began to act aggressively. When he got upset, he'd hit, bite and pull people's hair – acting out in ways he'd never done before. Sometimes, when [the therapist] arrived, he would refuse to go downstairs.
—Leah Hendry[66]

There are also concerns that abusive treatment may lead to aggression. Pent-up emotions such as frustration or fear may lead a distressed child to act out in ways they wouldn't otherwise.

If you look at photos of kids in ABA, you might notice that not all of them look happy. Some are rubbing their eyes, turning away, sitting very rigidly, covering their faces, or otherwise showing signs of discomfort/unhappiness. An ordinary parent or decent therapist might recognize this as a sign that the kid needs a break or a change of pace. But in ABA, a therapist may not stop getting in the child's face regardless of how upset they are.[52]

If you asked politely for someone to stop pestering or tormenting you and they didn't, you might ask more loudly or less politely. When that didn't work, you might even shout or cry. When that didn't work, you might try to leave. When your tormentor physically forced you to stay in the awful room, you might start pushing them, hitting them, throwing things, screaming, or engaging in other types of drastic behavior.

But ABA focuses on controlling the child's behavior, not on listening or understanding, so kids may be pushed to the point of violence when nothing else works.

Concerning responses to criticism[edit]

When hearing "some children have been abused and traumatized," the typical ethical human response would be "that sounds awful and we need to investigate this and ensure it never happens again."[citation NOT needed] Yet ABA professionals tend to turn defensive at the hint of suggestion that the ethics of their profession might need reviewing.

Check the comments in a discussion about abuse in ABA (even one that discusses a specific incident) and you'll see comments that boil down to "not my ABA" or "that's not real ABA and I want to ensure you don't think that about all ABA" (instead of maybe "give us the name of where this happened so we can investigate those horrifying allegations").[67][68] "Honestly, the hostility we get for sharing our negative experiences should really say it all," an autistic Reddit user has pointed out.[69]

Professionals in other fields have voiced concerns over ABA therapists attacking the reputations of professionals who have reservations about ABA, claiming that concerned critics are "spewing hate" and making "threats and accusations."[70]

ABA can be used for other conditions[edit]

Current insurance policies regarding coverage of ABA-derived therapies for children with autism have caused the term ABA to become synonymous with "autism therapy", as therapists in the US trying to do actually useful things label their work "ABA" to get it funded.

ABA therapy can be used for the treatment of OCD[71] and ADHD.[6]

Hi, parents![edit]

Look, there are many therapies for autism, so talk with a psychologist to figure out which is best for your child. Different kids have different needs. Not all autistic children benefit from ABA, and not all autistic children need any therapy. Look at what areas your child struggles with (like communication or assertiveness or anxiety) and focus support on those. Don't worry about the things that are odd but harmless; they're usually important to your kid's well-being.

If you want your child to have ABA therapy, but don't want your kid to end up traumatized, set limits on what the ABA therapist can do. For example, agree on ground rules like no aversives, no suppression of harmless stims, and your ability to review therapy goals. Always try to find an ABA therapist that understands you and likes your kid.

There are resources available to help you distinguish between helpful and harmful therapy.[72] Reading from and talking to autistic adults can also help you figure out what is and isn't a good idea for helping an autistic kid.

Keep in mind that ABA isn't your only option. A 2020 literature review found that DIR/Floortime, a much less rigid therapy, is promising, along with a therapy called Naturalistic Developmental Behavioral Interventions.[73]

Alternatively, let your autistic child autism autistically and don't try to turn them into yet another part of the neurotypical hivemind. You'll never succeed. They're always going to be autistic, and most likely everyone will be happier if everyone accepts that. Instead, look for ways in which you help your child be themselves within neurotypical society. Even the use of rewards to try and eliminate autistic traits can ultimately be harmful in the long run, as it teaches autistic children not to be themselves, which can have a negative effect on self esteem.

See also[edit]

Notes[edit]

  1. Some autistic people also struggle to control their mouths. Emma Zurcher-Long, for example, is able to type her thoughts independently, but will say random phrases that don't reflect what she thinks.

References[edit]

Warning icon.svg Content Warning

These refrences have a content warning for descriptions and discussion of child abuse and applied behavior analysis techniques.

  1. http://www.appliedbehavioralstrategies.com/what-is-aba.html
  2. 2.0 2.1 http://www.theguardian.com/society/2015/mar/20/autism-does-aba-therapy-open-societys-doors-to-children-or-impose-conformity
  3. Some still-current dimensions of applied behavior analysis
  4. "I'm sorry, but that's not earning your token"
  5. ABA overview
  6. 6.0 6.1 6.2 6.3 6.4 6.5 6.6 How much compliance is too much compliance: Is long-term ABA therapy abuse?
  7. The good, bad, and the ugly: my assessment of our experience with Applied Behavior Analysis (ABA)
  8. 8.0 8.1 http://pediatrics.aappublications.org/content/120/5/1162
  9. Efficacy of applied behavioral intervention in preschool children with autism for improving cognitive, language, and adaptive behavior: a systematic review and meta-analysis. - PubMed
  10. Applied behavior analysis and autism spectrum disorders: literature review. - PubMed
  11. Clinical Trial Compares ABA and Other Treatments - ASHA
  12. Early intensive behavioral intervention (EIBI) for increasing functional behaviors and skills in young children with autism spectrum disorders (ASD) - Cochrane
  13. Addressing the wicked problem of behaviour in schools - Taylor & Francis Online
  14. July 2015 letter from United States Department of Education
  15. An empirical update (1969-1989) of D. L. Krantz's thesis that the experimental analysis of behavior is isolated - PubMed
  16. Is ABA Really “Dog Training for Children”? A Professional Dog Trainer Weighs In. - The Aspergian
  17. Behavior Analyst Certification Board, Professional and Ethical Compliance Code for Behavior Analysts. bacb.com, 2014.
  18. What scientific idea is ready for retirement? Response by Simon Baron-Cohen
  19. ABA and the thorny problem of control and consent - Think Inclusive
  20. The Shocking Truth About ABA, Autism, and Abuse
  21. What If Everything You Knew About Disciplining Kids Was Wrong?
  22. O. Ivar Lovaas Interview With Paul Chance, 1974
  23. ‘The line between intervention and abuse’ – autism and applied behaviour analysis
  24. Screams, Slaps and Love (1965)
  25. The development of a treatment-research project for developmentally disabled and autistic children. - PubMed
  26. Lovaas, O. Ivar. Rekers, George A. Journal of Applied Behavior Analysis. Summer 1974. Behavioral treatment of deviant sex-role behaviors in a male child (Full text available).
  27. Winkler, R C. Journal of Applied Behavior Analysis. Fall 1977. What types of sex-role behavior should behavior modifiers promote? (Full text available).
  28. Nordyke, N S. Baer, D M. Journal of Applied Behavior Analysis. Fall 1977. Implications of the stereotyping and modification of sex role. (Full text available).
  29. Therapy to change 'feminine' boy created a troubled man, family says
  30. http://scienceblogs.com/insolence/2014/07/21/aversive-therapy-for-autism-and-developmental-disorders/
  31. http://www.cbsnews.com/news/controversy-over-shocking-people-with-autism-behavioral-disorders/
  32. http://scienceblogs.com/insolence/2014/07/21/aversive-therapy-for-autism-and-developmental-disorders/
  33. Theory of Mind and the Triad of Perspectives on Autism and Asperger Syndrome (Google Books)
  34. Authoring Autism: On Rhetoric and Neurological Queerness
  35. The Politics of Autism
  36. http://scienceblogs.com/insolence/2014/07/21/aversive-therapy-for-autism-and-developmental-disorders/
  37. Quiet Hands
  38. The Misbehaviour of Behaviourists
  39. Behavior Analysis Certification Board: BCBA Requirements
  40. On ABA and Rethinking Effective Behavioral Interventions - Think Inclusive
  41. touch nose. gummi bear: what is aba and why does it suck?
  42. They Deserve Good Teaching, Too - Rethinking Schools
  43. More on Scientific Un-Query - Tracy Kedar
  44. A Challenge to Autism Professionals - Ido Kedar
  45. Tweet by Autistic Science Lady, including a screenshot of the therapist's account. "SIB" stands for "self-injurious behavior" and is often a sign of severe distress.
  46. Quiet Hands - Julia Bascom
  47. Why I Left ABA
  48. Why we stopped most therapies - Respectfully Connected
  49. The Intense World Theory – a unifying theory of the neurobiology of autism
  50. Autism and Eye Contact - Judy Endow
  51. Increasing Sitting Tolerance for a Child with Autism Spectrum Disorder Using Positive Reinforcement, Negative Reinforcement, and Overcorrection Positive Practice
  52. 52.0 52.1 52.2 Invisible Abuse: ABA and the Things Only Autistic People Can See (Note: If you're decent at reading autistic body language, you'll probably notice this isn't right.)
  53. What Does Helpful vs. Harmful Therapy Look Like? - Maxfield Sparrow
  54. ABA - Maxfield Sparrow
  55. Hidden camera reveals ABA therapist interacting 'roughly' with autistic 4-year-old boy
  56. Unapologetically Non-compliant: A Neurotypical Mother’s Perspective After Leaving ABA
  57. Evidence of increased PTSD symptoms in autistics exposed to applied behavior analysis
  58. Evaluating Kupferstein's claims of the relationship of behavioral intervention to PTSS for individuals with autism
  59. The relationship of compliance with coping strategies and self-esteem.
  60. Undermining children's intrinsic interest with extrinsic reward: A test of the "overjustification" hypothesis.
  61. On ABA Therapy, Self-Determination, & Healthy Psychological Development - The Aspergian
  62. Prompt Dependency Beyond Childhood: Adults With Asperger's Syndrome and Intimate Relationships
  63. Helping or Hovering? Effects of Instructional Assistant Proximity on Students with Disabilities
  64. Life Skills Aren’t What You Think: What Research Says About Raising Autistic Kids - The Aspergian
  65. What Does Helpful vs. Harmful Therapy Look Like?
  66. Hidden camera reveals ABA therapist interacting 'roughly' with autistic 4-year-old boy
  67. See the comments here.
  68. A back-and-forth about ABA and abuse
  69. Reddit discussion on bad experiences in ABA
  70. An ASHA Certified SLP's Personal Perspective on Collaboration, Interprofessional Practice and ABA - SLP Neurodiversity Collective
  71. http://www.networkinterventions.com/your-child/obsessive-compulsive-disorder
  72. Tell if an Autism ABA Therapy Is Harmful
  73. Autism and Behaviorism New Research Adds to an Already Compelling Case Against ABA - Alfie Kohn