Applied Behavior Analysis (ABA) therapy should not be considered a therapy or treatment for autism. Even when it may not appear to be harmful, ABA is an inherently abusive and traumatizing practice. This trauma and abuse stems from a troubling history behind the practice, a lack of understanding among professionals about autism and autistic behaviors, and from ableism within healthcare. Autistic children face abuse in the name of therapy through punishments and aversives. They face abuse by being trained to be compliant and to not express their discomfort. They are taught that their natural instincts and behaviors are wrong — that for being autistic, they are wrong.
Endorsing Aversives and Torture
At its roots, ABA was a physically abusive practice designed by Dr. Ole Ivar Lovaas in the 1960s. Lovaas’ methods focused heavily on aversives to change autistic children’s behaviors, and particularly focused on eliminating stimming; he referred to stimming as “garbage behavior” (A., 2020). A stim is typically a repetitive behavior such as rocking or flapping, which serves to manage stress, cope with sensory overload, and regulate emotions. Stimming is a form of self-soothing and self-stimulation, and research has shown it is a healthy coping mechanism for autistic people to have (A., 2020). Lovaas punished children for stimming through shouting “no,” slapping them, and even through the use of electric shocks (A., 2020).
Electric shocks have been condemned by both the United Nations (UN) and the U.S. Food and Drug Administration (FDA) as torture (Ask an Autistic, 2019). Until March 2020 an ABA-based school in the United States continued to use this method to eliminate self-injurious stims and aggressive behaviors (Adams, 2020). This school, the Judge Rotenberg Center (JRC), only ended the use of electric shocks as an aversive when, after years of petitioning and advocating from disability rights groups, the FDA finally banned the practice (Adams, 2020).
This is an extreme example of the torture autistics experience in ABA. However, the Association for Behavior Analysis International (ABAI) featured the JRC at their 2019 annual conference; not only did they feature the JRC, but the presentation was focused on the merits of the electric shock device used at the center (ASAN, 2019). The fact that the ABAI would feature a presentation praising the torture of disabled children demonstrates that not only are they complicit in this abuse but also that the ABAI endorses this practice (ASAN, 2019).
Most ABA therapists do not resort to such extreme measures. A survey in 2008 showed that 25% of ABA therapists found electric shock to be an appropriate aversive to use, and over 33% looked to sensory aversives such as strong odors, unpleasant sounds, or foul-tasting substances (A., 2020). Both of these methods should be considered unforgivable — this is a blatant misuse of power over autistic children. Other forms of aversives include verbal disapproval, planned ignoring, withholding toys/comfort items/food, slapping, spanking, and the use of restraints (Ask an Autistic, 2020). Many of these methods are not widely used, but it is notable that there is not a restriction placed on aversives by the Behavior Analyst Certification Board; the board states only that aversives are to be used by those with “increased training,” and does not specify what this training entails (Ask an Autistic, 2019).
Positively Problematic
I do recognize, however, that most ABA therapists do not resort to aversives in their practice, but instead focus on positive reinforcement to modify behaviors. Positive reinforcement comes in many forms, from offering rewards like snacks or favorite toys, physical affection, or receiving a break. These rewards are withheld until the child complies with the therapist’s expectations, oftentimes when the child stops stimming or makes eye contact (Perry, 2018).
Many autistics who have been through ABA have disclosed that “tablet time” is used as positive reinforcement. This is a problem because many autistic people rely on their tablets for communication and/or as a form of stimming. Many autistics are non-speaking, and to take away their means of communication is one reason increasingly aggressive or “challenging” behaviors persist — they are not being heard or understood and the only way left to communicate their discomfort, pain, or any other needs has been taken away.
As Julia Bascom, the executive director of The Autistic Self Advocacy Network (ASAN), states, “Children in ABA programs learn that their body is not their own… that the way they move is wrong, that there is no neutral way for them to naturally exist in the world (Perry, 2018).” Children are left without adequate forms of communication or without proper accommodations to seek their needs. Their movements may be restricted or their bodies moved against their will. Methods of self-soothing are taken away, and other means of comfort are withheld.
These issues are further explained by a former ABA therapist who says:
… kids are repeatedly forced to do things that are unnatural, uninteresting, or even painful to them, all in the name of “therapy” – and all with smiles and upbeat attitudes from the therapists demanding it. The kids may cry. They may try to escape. They may refuse. But they must do it, because we have decided it is good for them and that we are helping them. They just may not be able to see it or understand it at the time. (AnxiousAdvocate, 2015)
While each child may have their own individualized therapy goals, it is ultimately up to the therapist to determine which behaviors are unacceptable. Other than stimming or making eye contact, ABA therapy might work to remedy walking on tip-toes, using echolalia (repeating words or phrases), perseverating on a specific topic, having an intense interest, covering ears, or not playing with toys in a typical fashion (AnxiousAdvocate, 2015). These are all common autistic traits, and to deem them unacceptable behaviors is offensive. None of these cause harm, and any attempt to train the child out of doing these things will communicate to them that the way they exist in the world is wrong, and that the way they enjoy things and share them with others is wrong. There is nothing wrong with being autistic, but most services and organizations intended to serve autistic people will tell you otherwise.
Behavior Over Personhood
ABA, as a practice, was never intended to validate or accept autistics. Lovaas expressed in a published journal article that he intended for his patients to be afraid of their therapists and parents (AskAnAutistic, 2020). The primary goal of this treatment was to improve behavior, and no emphasis was placed on the actual well-being of the child. Improving behavior is entirely subjective, with goals based on societal expectations (A., 2020), and on other people’s perceptions of autistic traits and typical behaviors.
This emphasis on bettering behavior only helps those around the autistic child, as they are trained to comply and to conform to neurotypical standards; this has little to no value on the emotional and mental health of the child (A., 2020). Studies that show the success of ABA measure the “betterment of behavior,” but what they are really measuring is how well a child can comply with a therapist’s demands and act the way they are “supposed to” act (A., 2020), rather than in a way that is comfortable and natural.
In this way, ABA therapists are viewing autistic children not as people, but as the sum of their behaviors (birdmadgrrl, 2017). This is nothing new. This ableist line of thinking, while certainly shared by others outside of the ABA industry, is also strikingly similar to Lovaas’ own view of autistic children when he said:
You see, you pretty much start from scratch when working with an autistic child. You have a person in the physical sense — they have hair, a nose and a mouth — but they are not people in the psychological sense. One way to look at the job of helping autistic kids is to see it as a matter of constructing a person. You have the raw materials, but you have to build the person. (The Art of Autism, 2015)
Autistic people, no matter how they engage with others or the world around them, are people. This fact seems to be overlooked by neurotypicals and allistics (people who are not autistic), who believe they are helping autistics when in reality, they are causing unspeakable levels of psychological harm. Though some autistic advocates may disagree, I do believe that most ABA therapists genuinely care about their clients. A former ABA therapist points out, “I thought that because I cared about the kids’ well-being, because I had a strong desire to help them, everything I did must therefore be in their best interest” (AnxiousAdvocate, 2015). But you can hurt people you care about, even with the best intentions.
Stereotypical autistic behaviors and traits are largely misunderstood. Stimming and special interests are seen as extraneous, useless, repetitive, obsessive. What is overlooked here is the value of both stimming and special interests; beyond coping with stress, regulating emotions, or managing sensory needs, stimming and special interests are ways for autistic people to experience and express joy. Focusing on eliminating these behaviors would be taking that joy away along with every other benefit they provide, and for what? To fit in a little better with neurotypical peers? A more useful change would be for society to learn how to accept autistic people for who they are instead of making autistic people try to become something they are not.
Trauma in the Name of Therapy
Pretending to act like their neurotypical peers, also known as masking, is emotionally fatiguing and traumatizing; being forced to do this in therapies like ABA can lead to developing Post Traumatic Stress Disorder (PTSD) (Autism Mythbusters, n.d.). A survey of 460 autistic adults and caregivers of autistic children evidenced that 46% of those who participated in ABA therapy met the diagnostic criteria for PTSD, and 47% of those meeting this diagnostic threshold experienced severe symptoms (Kupferstein, 2018). Based on this study, Kupferstein (2018) predicts that “nearly half of ABA-exposed autistic children will be expected to meet the PTSD criteria four weeks after commencing the intervention…”
The survivors of conversion therapy and ABA describe similar trauma (ASAN, 2019). Lovaas helped to develop both of these therapies, and they share a similar goal: to make the patient conform to society’s standards by changing their behaviors. “In fact, many autistic adults have started calling ABA ‘Autistic Conversion Therapy’ because it bears a strong resemblance to conversion therapy that the LGBTQ+ community has faced” (Kaylene, n.d.). Just as gay conversion therapy perpetuates the shame and stigma of being LGBTQ+ (The Trevor Project, n.d.), ABA upholds the stigma behind autistic behaviors.
Lovaas considered ABA a success when the child was made to be indistinguishable from their peers, and as one autistic self-advocate eloquently writes, “A therapy with the primary goal to make a person change who they are at the deepest level should never be acceptable” (Kaylene, n.d.). Conversion therapy and ABA both negatively affect mental health by punishing young people for being themselves. This is linked to depression, substance abuse, decreased self-worth, and suicidal thoughts by reinforcing society’s prejudices within a therapy setting (Human Rights Campaign, n.d.).
Ineffectively Evidenced
Yet ABA is still widespread throughout the United States and it is recommended under the premise of being an effective evidence-based practice. However, there is weak evidence that ABA is an effective behavioral treatment. Rated on the GRADE system the quality of evidence is low to very low (Reichow, Hume, Barton, & Boyd, 2018). In fact, “[o]f the 58 studies done on Lovaas’ ABA therapy, only one was found to meet the U.S. Department of Education’s standards for scientific evidence” (A., 2020).
This is not the only flaw in ABA research. Research about the effectiveness of ABA therapy excludes both non-speaking autistics and those with an intellectual disability resulting in an IQ lower than 70; these groups constitute a significant percentage of the autistic community (25% and 31%, respectively) and also are the ones frequently receiving intense numbers of hours of treatment each week (Kaylene, n.d.). For all treatment plans, a child is typically expected to participate in 25-40 hours of ABA therapy each week; that is 5-8 hours a day of repetitive, uncomfortable, or potentially painful demands and broken down tasks, of few or no breaks, of being presumed incompetent, and of not having adequate accommodations (AnxiousAdvocate, 2015). A full-time job is expected of kids under the age of 4, and there is no strong evidence to suggest that it is effective or beneficial. Further research is needed on neurotypical children in treatment for 25-40 hours per week, as a comparative group.
Ignoring Children’s Needs
Even if strong research existed to support ABA’s success, this research is only measuring how effectively it changes behavior. Managing behaviors may help with others’ perceptions of the autistic person, but there are no long-term studies to show any internal or emotional benefit (A., 2020). The intensity, discomfort, and stress of ABA therapy can lead to an increase in “challenging” behaviors, sensory overload, and meltdowns (Ask an Autistic, 2020). Sensory accommodations are too infrequently available in ABA, which inadequately supports autistic children’s diverse sensory needs.
ABA relies on subjective observations of specific behaviors (birdmadgrrl, 2017), but many autistic behaviors can be misinterpreted by those who are not autistic. The feelings of pain and discomfort from sensory experiences, of relief and liberation from stimming, of anxiety and frustration leading up to a meltdown — these cannot be understood from an allistic point of view. Behaviors can be changed through ABA, but the meaning behind them tends to be overlooked. When this happens, the autistic person’s needs are being overlooked.
A meltdown builds up when an autistic person’s needs are not met until it is no longer tolerable. Autistic people are not intentionally having meltdowns. However, meltdowns are often viewed as “attention-seeking behavior,” something that ABA therapists are trained to ignore (birdmadgrrl, 2017). Instead of being interpreted as maladaptive, these behaviors should be recognized as adaptive responses to, and protests of, the maladaptive environments that the autistic child experiences (Autism National Committee, n.d.). Instead of interfering with a meltdown, give the autistic person space and look at what sensory, bodily, and emotional needs have been overlooked. Accommodate the autistic person by fixing their environment rather than punishing behaviors beyond their control.
Meltdowns are not a tactic to get attention, and it is ableist to treat them as such. While attention-seeking behaviors are ignored, is it not unreasonable to assume that social, interpersonal, or sensory needs are being ignored as well. In order to ignore a child’s behavior, the child is also being ignored (birdmadgrrl, 2017).
Compliance Training
In the process of ignoring these behaviors, “you can’t give in, because then you are only reinforcing [the child’s] bad behaviors and making it more likely that they’ll use them in the future” (AnxiousAdvocate, 2015). This is also the case when the therapist gives a command; children are not able to refuse or say “no,” because their needs or distress are not being recognized or validated.
Within ABA, children have to appease their therapist in order to receive snacks, toys, attention, or a break. It is a similar tactic as is used by abusers, who will withhold attention or affection to gain control over the victim, and shower the victim with praise or other rewards when they comply with the abuser (birdmadgrrl, 2017). The grooming of abuse victims parallels the compliance training experienced in ABA.
Compliance training is an integral part of many ABA programs (AnxiousAdvocate, 2015). In order to progress through therapy, to be seen as competent, and to be deemed successful, autistic children in ABA must do what the therapist says even if it is uncomfortable. They must learn to comply with the demands they are given, no matter how unnatural it feels or how much they do not want to perform a given behavior.
These behaviors might not be painful or unpleasant to a neurotypical person, but this is because the different sensory needs of autistic people are often ignored. It communicates to the child that their experience of the world is not valid or acceptable, and that they are wrong for their perception of the world. It communicates to the child that their own discomfort and pain should be ignored if they want to be accepted (AnxiousAdvocate, 2015). This message is dangerous and it can leave autistic children more vulnerable to future abuse. Teaching autistic people to ignore their discomfort is also psychologically damaging and deeply rooted in ableism.
Ableist and Oppressive
ABA is not the only ableism autistic people face in our society, but it is the most marketable. The average ABA center will gross over $820,000 a year; the industry itself is valued at over $1.8 billion (SOS Franchising, n.d.). It easily costs over $50,000 a year for one child to go to ABA therapy for even 10 hours a week. It is not unusual for a child to attend for several years up to 40 hours a week (Raypole, 2019).
ABA is effectively marketed to parents of autistic children through fear, and this fear is heavily rooted in ableism. It makes the assumption that a person’s worth is based on how well they perform arbitrary tasks, and insists that ABA is the only way to “fix” them. This assumption only works if you believe that there is something wrong with being autistic, and I assure you there is not.
Parents are afraid that their children will not grow up to meet society’s expectations of working, of living independently, of leading typical lives. These fears are unrealistic, as many autistic people can do these things without therapy, but also these expectations do not encapsulate a perfect, happy, or meaningful life. Nonetheless, parents turn to ABA to try to make the best future for their kids, while ignoring what a happy future might look like. ABA is effective at changing behaviors, or in other words, teaching children to suppress autisitic behaviors so that they appear “normal,” but it is incredibly ineffective at making those same children feel safe, accepted, or accommodated (AnxiousAdvocate, 2015).
The ABA industry both capitalizes on ableism and helps to maintain a power hierarchy. It actively oppresses autistic people through the mistreatment and abuse reported from ABA sessions, and by exploiting autistic people’s families, fears, and insecurities. It highlights the power struggle between two groups: Autistic and Not Autistic, in which those who are autistic are the minority group. This is a subset of two different groups: Disabled and Not Disabled. Those who are neurotypical and able-bodied are in both of the dominant groups in this case and they benefit from this privilege. Ableism is perpetuated by the dominant groups when being autistic is seen as wrong and not as an identity, a different neurotype, or a different way to understand the world.
Those autistic people who are most disabled in the eyes of society are even more likely to be subjected to ABA for the most years, the most hours per week, and are the most likely to experience the use of aversives (Autism National Committee, n.d.), compared to their counterparts who are seen as “high-functioning”. Punishing autistics for acting like themselves is ableist, and is a human rights and civil rights issue. The way these children are treated in ABA would be unacceptable ways to treat a neurotypical or non-disabled person and has been argued that this treatment is too inhumane to use to train animals (Autism National Committee, n.d.). The ableist treatment autistic children face is denying them equal protection under the law from aversives and other mistreatment (Autism National Committee, n.d.), all in an attempt to “normalize” them (AnxiousAdvocate, 2015).
Nobody Needs ABA
The harm of ABA therapy far outweighs any potential benefits. Yes, outside of learning to mask autistic traits children can learn useful skills in ABA, but further research is needed to assess the likelihood of these skills being learned at home or later in life. In online autistic spaces it is recognized that autistic people learn many of these skills outside of ABA therapy. Autistic adults don’t act like autistic toddlers because they are adults. While autism is a developmental disability, it does not mean that autistic people never develop skills, they just may do so later in life and at a different pace than neurotypical peers.
ABA is one potential strategy for teaching autistic people these skills so that they fit in with their peers, but it is an incredibly harmful way to do so. Through surveys of over 2,000 participants, 93% of autistics have stated that they are against ABA (thecreativeautistic, 2019). Finding therapies specific to the autistic person’s challenges, such as speech therapy or occupational therapy for speech and functional skills, respectively, is a better use of time and money.
Many ABA practitioners are Registered Behavior Technicians (RBT)s, which any 18-year old with a high school diploma could be by taking a 40-hour training and passing an exam (Behavior Analyst Certification Board, n.d.). Other therapies have more highly qualified therapists who have completed more relevant coursework (based on the degree) and have spent countless hours in their field prior to certification; these therapists are more capable of focusing on specific skills and goals. ABA also often relies on the parents to reinforce learning because the skills are not easily generalizable to the child’s life outside of therapy, and because children learn through repetition.
ABA also highlights that perhaps it is the parents that need to learn additional skills to better understand their children (Walsh, 2011), rather than children needing to learn to change to fit into the rest of the world. Children should be allowed to have a childhood, and that is not possible when they must sit through 25-40 hours of therapy each week. This level of intervention leaves little time for rest, play, and learning outside of therapy, which can wreak havoc on a child’s mental health. Instead of stigmatizing autism and typical autistic behaviors, acceptance and accommodations are necessary on a societal scale. Without the ableism against autistics in the world, the primary goals of ABA are obsolete.
ABA provides an easy example of the oppression autistic people face in society. Often unconsciously, the ABA industry reinforces the ableism that autistic people experience every day by teaching children that the way they comfortably and naturally exist is wrong, that they do not have the right to say “no” to activities or unwanted touch, and that they do not deserve respect and autonomy. ABA and its supporters will deny or hide the torturous history of the practice and pretend that cases of abuse are incredibly rare. This is done while ignoring countless articles, blogs, and stories shared by autistic people speaking out against this “gold standard” of abuse.
Society at large does not understand autism, and researchers and major organizations all focus on the wrong things. Autistic people are human, and we deserve to be understood rather than changed, fixed, or cured. Autism is a neurotype, a way of being, an identity. Listen to autistic people when we tell you that ABA is wrong. Listen to us when we tell you that we are abused and traumatized. Autistic people need support, acceptance, and reasonable sensory and communication accommodations. We do not need ABA.
References
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A. M. (2020, January 30). ABA therapy: Treatment, or torture? Adultistic. https://www.adultistic.com/health/aba-therapy-treatment-or-torture
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Autistic Self-Advocates Against ABA 