As a parent of a child with autism, you are likely to have heard the term Applied Behavior Analysis (ABA) therapy. You are also likely to be aware that there are many controversies surrounding ABA therapy – and these are well worth exploring.
The aim of this article is to provide parents with the latest research on what ABA is, the strategies ABA therapists might include in a child’s program, and to discuss the efficacy of these methods. Another goal for this article is to compare examples of ABA as good practice therapy versus the “ABA therapy horror stories” of some approaches. Ideally, this will provide you, as the parent and the true expert of your child, with unbiased information to make a decision for his/her therapy path.
Although ABA has received accolades from many renowned professionals through scientific journal articles, there is always room to explore the evolution of understanding what therapy works and if this might be outdated or against the philosophy of what we now know about autism.
As a starting point when researching ABA, it’s a good idea to speak to people with autism who have received ABA therapy. To hear their stories, to enquire why they liked or disliked and, most of all, what they found to be supportive and helpful (and what they did not) within certain methods. You can then form an opinion based on this knowledge for your own child and family. In order to include some relevant examples, writings of people with autism who received ABA as children have been included in this article.
First, what is ABA therapy?
Autism Parenting Magazine explains the basic principles of ABA in a guide which can be accessed by clicking here. According to most published, peer-reviewed journals, ABA is a scientific approach in which procedures are implemented to create a change in behavior. The goal for an ABA therapist is to change current “socially unacceptable” behaviors (such as self-stimulatory behaviors, aggression, or meltdowns) to more “socially acceptable” ones (such as utilizing “fiddle toys”, communicating needs effectively, and incorporating coping skills).
As a research psychologist, when I read the above, it makes sense: if there is a behavior in my life that is unacceptable to society and it is within my means (and interest) to change it, why wouldn’t I? There are, however, a few basic human rights issues when we make these decisions for a child that might be non-verbal or unable to understand at that stage the reason behind our methods or strategies.
Another goal for ABA therapists is to increase vocal speech by including discrete trial teaching methods (repetitive in nature). ABA therapists include hand-over-hand prompts to teach physical tasks, where a child is helped (prompted) to complete activities and these prompts are then faded systematically to work towards independence. Reinforcement is a strategy that ABA therapy utilizes where a child receives praise or (parts of) items (which can include snacks or games) for short periods of time. Before reinforcement is established, an ABA therapist would conduct a “preference assessment” to determine your child’s level of interest for each item presented. These items are then ranked – highest motivating item to least preferred and for more difficult tasks, a child can receive a short period of time with the most liked one.
Other strategies of ABA include determining the function of behaviors and then reacting consistently in specific ways depending if these behaviors were elicited for escape, attention, a tangible or automatic. Some examples of this might include a child that walks away from a task (the function here would be for “escape”). The ABA therapist will ignore the walking away and redirect the child to complete the task before allowing him or her to take a short break or interact with a reinforcing activity.
Another example of behavior management according to ABA principles is to ignore a child’s craving for a sensory toy or sensory input and provide them with the command “hands down” when they are engaged in hand flapping (self-stimulatory behavior). Seeking out attention from someone is a behavior that is often dealt with in a very specific manner within ABA. When a child looks for attention in, what is considered by the ABA therapist, to be an “inappropriate” manner, the behavior will be completely ignored. The idea is to teach the child that the “inappropriate” behavior will not get him/her the attention that he/she is looking for. However, the more important aspect to take into consideration here is that there is a child looking for attention. What needs to be taught is that attention is given to a child when they have the need for attention and easy, functional ways for seeking out attention need to be taught to the child on a consistent basis.
ABA sessions are often recommended by pediatricians and the hours usually agreed upon by providers range from 20 – 40 hrs per week of one-on-one sessions. These sessions mostly involve a supervisor that will write out an Individualized Educational Plan (IEP) for your child, clearly stipulating specific goals with suggested strategies. The supervisors usually hold a BCBA (Board Certified Behavioral Analyst) and Masters-level degree in Psychology.
Depending on where you go for ABA therapy, your child might have a team of ABA therapists who each do 1.5 hours to three hours of therapy and then a new therapist starts another session. These sessions typically include table-top work and some break activities. A major focus of the sessions is on preverbal and verbal communication, such as oral motor activities (copying mouth and tongue movements) as well as imitating sounds and words. Another initial goal in ABA is compliance, where your child is taught that complying to instructions such as “look at me”, “sit down”, “come here”, “give me (object)”, etc. will be reinforced.
Some of the strategies that ABA therapy utilizes are included in many other forms of therapies. Visual resources are heavily emphasized by most autism therapies, by advocating for visual schedules, visual choice boards and preparing a child for an upcoming transition by utilizing social stories or “first-then” schedules. Although these strategies are sometimes linked to ABA therapy, it originated from various parenting strategies and other modes of interacting with children. Social stories, for example, were developed by Carol Gray and have since been adapted to various forms of therapeutic settings and quite frequently used in Speech and Language Pathology sessions.
ABA has evolved through the years and just like with any form of therapy or interaction there are ways of creating ABA-like strategies that are useful, successful and even needed for any child. The difference is that through the years of evolution and sifting through the ABA therapists that understand the reason for implementing certain strategies and the ones that don’t, there is another argument that should be considered. If the philosophy of ABA is to change the child and the goal is to create individuals that are neurotypical (or “normal”) will that not do more harm than good to your child’s self-esteem?
Is ABA therapy effective though?
It might be useful for parents to look at the efficacy of ABA therapy and include these into their therapy plan for their child. Here is a list of strategies that might not be invented by the developers of ABA therapy, but that are being utilized throughout ABA sessions:
Five effective ABA strategies that can be adapted:
1. Positive reinforcement
Although positive reinforcement can instil feelings of working for something that is only received for a little while, it can also be implemented in a successful and effective manner. If a child knows he or she needs to complete a task before a preferred activity is introduced, the child might be more motivated to do so.
A child should be encouraged to complete interest-based activities and not always work for a short period to engage in an interest-based activity. Autistic or neurotypical – we all enjoy learning more about our interests.
2. Naturalistic Teaching
Once a child has mastered a certain goal or a few goals, an ABA therapist would usually include these in his/her “NT” sessions. This might include outings and generalizing skills learnt in a one-on-one session.
Although NT activities are great, an adapted way of including this strategy would be to include it from the start within your child’s program.
As with NT sessions, generalization can be a great strategy to include in all sessions. When we teach a child (through their interests) about a certain topic, we should ideally teach them this topic in various ways, in different environments, and with a variety of people. For example, if we teach our child the color blue, we can show him/her many different blue items around them, how to spell the word blue, how to say blue and request for blue items he/she likes, including these activities with more than just one therapist or parent.
Generalization should ideally be included from the start, when you introduce a new goal or target to your child. It is understood that many people with autism struggle with generalizing skills learnt from one environment to another – this is all the more reason to include this strategy early on.
4. Video modeling
Where a child observes a certain (“socially acceptable”) behavior by watching a video and then imitating that action. This ranges from a child watching another child saying a sound or word correctly and then copying this to gross motor actions, such as jumping on a trampoline or playing appropriately with a pet.
Video modeling can also be adapted to fit into the budget of the family, as many of these video modeling programs or apps can be quite expensive. A good idea is to create your own short videos to replay to your child by including people that he or she knows and likes. You can focus on one goal – for your child to learn to pronounce certain sounds clearer and more refined. Ask your child’s speech therapist (if you have someone to refer to) which sounds are typical to learn for your child and also his or her age.
Ask some of your family members to create short (and fun) videos making these sounds and try and keep it functional. For example, if the sound is “ssh”, you can ask one family member to pretend to say “ssh” to soft toys (or other items) around the house. Another family member can say “shoo” to a character or person close to them (as a joke) and another can possibly say “shoe” and point to their shoe in the video in an animated way. The idea here is to entertain your child with videos that are functional, fun and practical and ideally your child imitates the sound or word when watching these videos.
5. Prompting (helping)
This strategy is widely used with all children, where we as adults help them to feel successful. The idea behind prompting is for a child not to become frustrated and give up.
It is important to see prompting as a tool that should be faded and also only included when needed. We should provide our children the opportunity to try before we help and also to know that being “wrong” is not the worst thing that can happen to them. This way we are working on increasing their perseverance and their ability to utilize coping strategies that will benefit them in the future. In short, if you are going to prompt your child, wait to see if they don’t find a different way to solve the “problem” and then let them know that asking for help is fine.
There are more ABA principles that can be adapted – read more about these here.
Click here to find out more
What do people with autism say about ABA?
If your dream is to become a world famous tennis player, I suspect you would love to speak with people like Rafael Nadal, Roger Federer and Serena Williams. It would be an important time to ask their expert opinion and learn from their victories and possible mistakes in becoming and being the professionals they are in the field you are interested in. Similarly to this, when we want to find out what is best (and worst) for individuals on the autism spectrum, we should regard the opinions of adults on the autism spectrum. They experience some of what our children go through on a daily basis – they understand the needs and requirements better as they experience the world more intensely than most neurotypical individuals.
There are generally two schools of thought regarding ABA therapy – one group is heavily against the application of this type of therapy, which usually includes many autistic adult advocates and some therapeutic modalities. The other group includes mostly professionals and ABA therapy providers, who believe that the research backing the application of ABA techniques should be considered when choosing a therapy path for your child. The group that is not mentioned here includes the parents of these children.
When your child is two or three years of age, you as the parent of course decide what is best for your child. Now, considering that autism is still relatively “new” as a diagnosis and our understanding of the prognosis still limiting, surely we should consider all these schools of thought before making decisions? We have discussed some effective strategies that are familiar to professionals through the inclusion of these in ABA programs. Let us discuss the opinions of people who are against ABA.
ABA therapy horror stories from adults with autism:
- Amy Sequenzia is an adult on the autism spectrum who publicly speaks about the effects of ABA therapy on individuals with ASD. You can read more about her experience by clicking here. In general, Amy states that ABA therapy takes away a child’s basic human rights – to say “no” when they want to, being forced to comply to an ABA therapist’s every demand and that the ultimate goal for ABA therapy is to “normalize” an individual in a box they do not want to fit into. Her writings are powerful as an account of someone who severely rejects the idea of ABA, who is autistic and has found a way to be independent and happy.
- Max Sparrow (formerly Sparrow Rose Jones) is an autistic author, artist, advocate and speaker. Max eloquently provides an article on ABA from parents’ as well as autistic adults’ viewpoints, stating that neither of these groups are “incorrect” in their thinking. He also includes controversial thoughts on why some therapies are still labeled as “ABA” to cover parents’ fees through insurance coverage. This is a topic that deserves more consideration as parents are paying exuberant amounts of money to cover their child’s therapies and if this can be covered through insurance it will be more sustainable. Thus, more therapies are perhaps being labeled as ABA in the hopes of more families receiving support services. Read Max’s writing here.
- Alexander is an autistic teenager and he writes of his experience “escaping” ABA sessions. You can read about his reasons for disliking ABA here, but in general he felt misunderstood and belittled during his sessions. He believes that ABA therapists are too rigid and will not take into consideration the unique characteristics of each individual. Although there are ABA therapists that will say “not all ABA is the same”, it is important to understand that the philosophy of ABA, with the goal to change a child’s innate behavior to a more socially acceptable form is not respected by some autistic people.
- Eileen is a mom with a child on the spectrum. She writes a blog that shows an unbiased viewpoint from a mom who believes that some ABA strategies can be useful. She believes it is useful to integrate therapy options that are covered by insurance as this is a sustainable option for families in the long run. Her blog can be read here.
- Ido Kedar is an author, blogger, and speaker who is nonverbal and on the spectrum. Ido wrote an open letter to professionals, challenging them to look beyond our studying of autism and rather at the child in front of them. He mentions that he too felt misunderstood and frustrated throughout the years of receiving ABA therapy, but that he was freed when his parents found a way for him to communicate his real desires and display his different type of intelligence. You can read more about Ido here, where you can also find information on the book he wrote, Ido in Autismland.
So, should parents choose ABA for their children?
As mentioned before, you – the parents – are truly the experts when it comes to your child. Yes, we want our children to voice their opinions, needs and wants, which will be respected, but as parents we take on the responsibility to provide what we feel is best for our children.
When I speak to parents of children that I worked with many years ago, who all received ABA therapy, they all agree that certain strategies worked extremely well for their children. These are strategies though and not the philosophy of their child needing to change who he/she is, what he/she likes, and how he/she communicates these needs. When I speak to the children that I worked with many years ago they mention very little of what they disagreed with, but that they are happy with the way some of the sessions are done now. If I ask my nephews and nieces who are grown up now what they liked about school, some might mention that they didn’t enjoy it at all. So, how do we make a decision for our own child? We do the research, we ask the people that we have met in the field and we go with our gut.
What we do know is that the brain of an individual is always evolving, always able to build new neural pathways, and these stay elastic. There is always time to learn a new skill, take a language course, or change your current habits. How is this different for our children? Yes, some studies show early intervention is beneficial, but my personal advice would be to slow down before jumping to the first service provider you find, and take a look at your child. What do you truly feel would be best for him/her? Would your child cope in a strict behavioral setting or does he/she require a more fluent and easygoing therapist?
A great analogy I once heard was about the teachings of yoga. Ashtanga and Iyengar are both well researched and respected yoga styles. The names of these practices haven’t changed much, yet some yoga practitioners have realized that the repetition of certain sequences and poses within these practises lead to body ailments. Instead of “shaming” the yoga style, they removed the positions that lead to delayed pain and continued practicing good yoga sessions.
Now, let’s assume we can do this with ABA – perhaps we can remove the delayed pain it might cause some autistic individuals, the philosophy of trying to change a person, repetitiveness of certain tasks, and enforcing reinforcement schedules? Maybe then we then find a way to continue utilizing the effective, fun and interactive strategies that our children do need and help parents and children by supporting them the best way we can.