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What Is The Controversy Behind ABA Therapy?
Applied Behavior Analysis is currently the most common method of treatment that is prescribed by physicians for autism spectrum disorders and other behavioral disorders. It has often been referred to as the “gold standard” treatment for children with autism and other developmental conditions.
This reputation has been established over time as ABA has collected decades of data based evidence of its effectiveness with children who have received ABA treatment. The evidence consistently shows increased communication skills, improved attention, decreased problem behaviors, improved attention skills and improved social skills- just to name a few.
But, just like anything “good for you” or “popular” or even something factual that has a proven history attached to it, there will always be opposition to counter all of the claims in favor of….ABA in this case.
In fact, the very elements of treatment that have made ABA so effective and successful as a treatment for autism spectrum disorders are the same elements that are causing upset and controversy among the opposition.
What is the controversy? What is it about applied behavior analysis that people are opposed to? To put it simply, the biggest complaint from the opposition is that ABA is an overwhelming and cruel attempt to force children with autism to appear or behave “normal”. Those who oppose ABA would prefer to promote neurodiversity, “ the idea that people with autism or, say, attention deficit hyperactivity disorder or Tourette syndrome, should be respected as naturally different rather than abnormal and needing to be fixed.”
Is ABA Therapy Too Tough on Children with Autism?
One of the criticisms that is commonly heard is that ABA is too tough on children with autism spectrum disorders. Much of this opinion stems from the early 1960’s principles of applied behavior analysis and the use of Discrete Trial Training (DTT). Discrete trials were done in a clinical setting by requiring a child to sit at a table while a therapist presented the instruction (stimulus) in a formal teaching manner and waited for the child to respond. For example, the therapist would present two color cards (yellow and red) and say “touch yellow”. The child would then respond correctly by touching the yellow card. If the child touched the wrong color card or failed to respond or left his/her seat- then that would be an incorrect response.
Depending on how the child responded, the therapist would deliver reinforcement or correction and repeat the procedure for a predetermined number of times. It could be ten or twenty depending on what the treatment plan called for.
Try to imagine yourself as that child with autism, back in the 1960s, sitting in a clinical environment with an overly formal clinician. Imagine that you cannot express yourself verbally and you are being asked to repeat the same task over and over again during discrete trial training (DTT).
If the task is too easy, then you may feel frustrated and refuse to comply or you may push the cards away. If it is too difficult, you might get angry and cry. But, the clinician will continue to press on and ignore the negative behavior and present the cards again because the task must be repeated ten or twenty times and data must be taken. The emotions of the patient were not the primary concern during therapy. The focus was primarily on shaping the responses and the behaviors. This is where the controversies began and they began when the patients came of age and started to tell their stories about what it felt like to be on the other side of the treatment plan.
The Early Years: Prior Use of Punishment in Therapy
In the early days of ABA, positive reinforcement was not the primary instrument of behavior change that we are familiar with today. The use of positive reinforcement, negative reinforcement and punishment procedures were all commonly practiced forms of treatment in the early stages of ABA. Electric shock therapy was also a method that was used to stop patients from harming themselves or others.
As absurd as that sounds, electric shock therapy was usually implemented as a last resort to reduce or eliminate behaviors that were dangerous or potentially fatal to others or to the patient themselves.
Secondly, electro shock therapy is still used in neurological settings but it is usually done in a surgical setting under general anesthesia for the most severe symptoms that do not respond to medications like seizures, depression or certain psychological disorders, but it is rare and risky.
Evolution of Ethics
We have come a long way since the 1960s and 1970s with regard to patient rights and protections. Prior to the Sunland Miami Scandal in 1972, when an unregulated behavior modification program led to horrific abuse of patients, there was no official code of ethics to protect a patient during behavior treatment. “The Sunland Training Center in Miami became “ground zero” for an abuse investigation that rocked the state of Florida in 1972.” (Bailey & Burch, 2016).
Sadly, “…the horrific abuses at Sunland Miami in the early 1970s were probably necessary for half-baked, unregulated behavior modification to evolve into professional, respected, behavior analysis. Without the abuses, there would have been no Blue Ribbon Committee formed to think seriously about how to protect developmentally disabled individuals from systematic abuse of behavioral procedures.” (Bailey & Burch, 2016)
“Although it would have been easier to prohibit behavior modification altogether, the Blue RibbonCommittee was convinced by its two behavioral advocates, Drs. May and Risley, that a better alternative was to establish strict guidelines for treatment and to set up an infrastructure for oversight involving community citizens who would bring their values, common sense, and good judgment to evaluate behavioral treatment strategies on an ongoing basis.” (Bailey & Burch, 2016)
Do We Still Use Punishment in ABA Therapy Today?
Yes, we still use punishment in ABA therapy today. However, it is important to understand the actual definition of punishment before making any judgments. “Punishment occurs when stimulus change immediately follows a response and decreases the future frequency of that type of behavior in similar conditions”. In other words, punishment is a change of stimulus or consequence that occurs immediately following a child’s response that would decrease the likelihood of the child repeating that particular response again. For example, if a child plays on their tablet without permission before homework is done; the consequence could be that the tablet is locked away for a day or two (response cost). Ideally, the chances of that child playing on the tablet without permission before homework is done will decrease. This is the exact opposite of the definition for reinforcement which would increase the frequency of a behavior in similar conditions.
One example of punishment would be response blocking. This is something that many parents naturally do when one child tries to hit another child in the family and we intervene and stop them from hitting. We block the response.
Another type of punishment is overcorrection. Let’s say that a child slams a door in anger. A parent could use overcorrection to require the child to go back and close the door several times to “practice” closing the door correctly or require them to close it as many times as it takes to close it gently and correctly if they are still having trouble controlling their anger.
Response costs are also a type of punishment that “take away” or impose a cost for inappropriate responses. For example, if a child is working on staying in his/her seat for a certain amount of time and they are working with a token system, the therapist can remove a token each time the child leaves his/her seat.
Reprimands are the most automatic and familiar type of punishment to most parents. When we find ourselves chanting, “Don’t do that!”, we are reprimanding and trying to decrease a behavior.
While punishment is not the first method of choice for teaching and correction, it is still a valid choice and sometimes necessary. The problem that most people have with the idea of punishment is that they equate the term with abuse and cruelty. Punishment should never be done in a way that is harmful to a child. It should only be used to make the undesired behaviors unpleasant or ineffective to repeat in the future. For some children, overcorrection will be enough to avoid slamming the door again. For others, it might take losing a token or a dollar from their weekly allowance.
The key to using punishment procedures is to make sure that there is plenty of opportunity for positive reinforcement for appropriate behaviors. We don’t ever want to set a child up for an entire ABA session or a day filled with frustration because they are being reprimanded the entire time. The goal is to find a way to direct them back to desired behaviors and continuously encourage them with positive reinforcement and keep the momentum going in a positive direction so that they want to keep the praises coming at them!
Modern Day ABA Practices
Positive reinforcement is at the core of everything we do in ABA therapy. The sterile clinical environment is in the past where it belongs. Unregulated behavioral modification programs are also in the past where they belong.
There may be times when it is appropriate for a child and their therapist to sit at a table in a clinical setting and do some work, but when it is obvious that a child can no longer focus their attention on the work then it is the responsibility of the therapist to give the child a break and keep frustration from settling in. It is also worth mentioning that a clinic back in the 1960s and 1970s looked much different than what we see now.
When you walk into an ABA center today, such as ours at Circle Care Services New Jersey, you are likely to see a room filled with equipment that is specifically designed for children who have sensory issues. There are hammock swings that squeeze a child into a fetal position while they swing, crash pads for children who need to bang their head or other body parts into people or object, weighted medicine balls for children who tend to throw objects due to frustration, yoga balls to sit and bounce on, pads and balls to roll over and on the child who likes to feel squeezing or pressing for relief and much more.
By keeping things fun and by keeping sessions highly reinforcing with positive reinforcement, there should be little need for punishment procedures. If there is a need to use them, the positive reinforcement and redirecting the child back to appropriate behavior would far outweigh any of the punishment procedures mentioned above (reprimands, overcorrections, response cost, and response blocking).
At Circle Care Services, we understand the concerns that parents have about finding the right team of professionals to help your child. If ABA is new to you and your family, it can be overwhelming trying to sift through the vast amount of information that is available online. The lingering controversies of the past can leave parents of a newly diagnosed child with autism feeling conflicted and anxious. We have a great team of professionals at Circle Care Services who can answer any questions or concerns you may have regarding ABA therapy and practices. We also encourage building community with other families in New Jersey who are experiencing some of the same joys and challenges with their children.
Eliminating Behaviors
Surprisingly, another controversial area of ABA therapy is the topic of eliminating autistic behaviors. Most parents are seeking ABA services for the purposes of eliminating socially awkward or inappropriate behaviors. However, as time has progressed and some of the patients of ABA have grown up to voice their own opinions, it has become increasingly clear that there is a population of people who did not appreciate being forced to hide their autism.
The opinions and feelings from the parents and the grown children with autism ranged from mildly irritated over the feeling of being overly compliant to claims of outright abuse and PTSD over being forced to make eye contact or feeling controlled.
ABA therapy is never about force or control. ABA therapy is about teaching a child with autism the skills that they will need to communicate and to be able to do what their peers are doing. It is never the goal to remove someone’s identity or to cause anyone to feel less valuable because of a label or a disorder. The goal of ABA is to work in conjunction with a family that is seeking help because the child and the family is struggling with daily living.
Helping a person with autism to communicate a want or a need should not be torturous. Teaching eye contact should not be something that feels like a control issue. There are opportunities when a child will make eye contact and it is at those times that the therapist will use positive reinforcement to praise the child in hopes that they will repeat the eye contact again. There is no need to grab their face and demand that they look at you. Seeking opportunities to praise them is enough.
Stimming (flapping, clapping, waving, or any other repetitive movement or vocal tic) is another area that people with autism take issue with. Many former ABA clients have spoken out against being taught how to control their stimming behaviors in public. This is an automatic behavior that helps people with autism to regulate emotions and by teaching them to withhold this behavior, many people with autism struggle with frustration and anxiety.
There is a running sentiment from a segment of the autistic community that wants to be appreciated for their neurodiversity. This part of the community does not want to be “fixed”.
At Circle Care, we are not here to “fix” your child. We are here to teach and to help children and families that are struggling with daily living skills and academics due to autism or other behavioral disorders. We appreciate everyone in all of their diversity and uniqueness and we want everyone to have skills for success.
Overly Formulaic/Robotic/Ignoring Emotions
If you have ever heard that ABA therapists are “robotic” and that they lack emotion during therapy then you are probably speaking with someone who had a bad therapist. Discrete trial training can be boring and tedious if you don’t put some fun and momentum into it. Just think about the description of that sterile clinical setting of the 1960s that was mentioned above.
When a therapist is sitting at a table with a child and asking a child to respond to a stimulus, they are trained to give an enthusiastic positive response to the correct answers and to quietly move on without response when the child answers incorrectly. This can easily be misconstrued as an emotionless response to the child. It isn’t meant to be emotionless. It is simply in contrast to the excited positive reinforcement that is given when the child answers correctly. Children with autism need that clear distinction and there is a method at work here.
The same method is used for tantrums when the function of the tantrum is attention. If the child throws themself down on the floor for attention because two adults are talking, then it is in the best interest of the two adults talking to ignore the child until the child understands that the tantrum is not the best method for getting attention. Then the child will perhaps try something else. If they say “excuse me” then positively reinforce that with immediate attention! “Yes? What do you need?”
Conclusion
There isn’t a topic on this planet that doesn’t have pros and cons. Your best recourse is to be a good consumer and to sit down and think about your short term and your long term goals for your child and for your family.
Do a quick search for controversies associated with ABA on the internet . Most of the sites for the controversies related to ABA are opinionated blogs written by people with autism, parents of children with autism or former teachers. None of the sites had any genuine evidence based research attached to them. All of them were passionate, but they were in all honesty emotional rants.
ABA is an evidence based science with decades of good outcome. Children who couldn’t communicate learned how to speak or use some sort of communication device. Many children with autism have improved their academic skills and joined the general population in school rather than being assigned to a self contained classroom. A large number of children with autism who receive ABA “outgrow” symptoms and blend right in with peers during high school and beyond high school. Many of them embrace their autism and speak openly about it in their careers later in life.
At Circle Care we are here to answer your questions and help you to make good decisions for your child. We are ready to show you how positive the ABA experience can be
with the right team of people on your side. Don’t let website controversies overshadow the overwhelming scientific evidence that ABA has provided for the last five decades.