One parent said, “Our involvement with ABA remains one of my biggest parenting regrets.” Another said, “This treatment saved my son from an isolated and non-productive life. ” A third: “The first consultation was trying.”
These are just a few testimonials regarding Applied Behavior Analysis (ABA), a therapeutic modality for autistic children that involves using positive and negative reinforcement techniques to teach children social skills. ABA is considered one of the most beneficial therapies for autism, as it offers hope for autistic children to live a socially normative life and integrate with neurotypical peers, and it’s one of the most popular therapies. Yet this exact goal of normalizing autistic children, combined with techniques that deprive autistic children of self-regulatory skills and an emphasis on teaching individual skills out of context, render ABA controversial, with some parents hailing it as a savior while others regret its use. It is this exact controversy that threatens ABA’s position as the definitive behavioral therapy for autism.
ABA came into use due to the work of behaviorists in the 1950s, who argued that psychology should focus on manipulating human behavior through learning or conditioning, rather than focusing on analysis of the thoughts and feelings underlying behaviors. Behaviorist techniques were first tested on animals, but the first human population to receive behaviorist treatment were intellectually disabled institutionalized children.
Prior to behaviorism, children were treated using Freudian principles, based on the belief that autism and other forms of developmental disability were born out of a lack of warmth and affection from so-called “refrigerator” parents. Hence, when autistic children acted inappropriately, they would receive hugs and affection to compensate for their parental deficit.
Behaviorism, and by extension ABA techniques, would change autism management. The first behavioral study done on autistic children was Ferster and DeMyer’s 1960 experiment, in which they used candy to reinforce positive behavior, demonstrating that autistic children learned just like other children and thus could be taught socially acceptable behavior. This study inspired the work of Dr. Ole Ivar Lovaas, known as the father of ABA. Lovaas began studying institutionalized autistic children who engaged in self-injurious behavior. During Lovaas’s initial study, institutionalized children received electrical shocks when engaging in self-injury. The resulting reduction in such behavior, according to Lovaas, demonstrated that so-called “abnormal” behavior could be “trained” out of autistic children.
In 1987, Lovaas used these dubious findings as a basis and expanded on his work in a thirteen-month study, in which one group of autistic children received 40 hours per week of instruction designed to teach language and social skills. The new study used isolation and painful stimuli, such as slaps, as negative reinforcement and food as positive reinforcement. The control group received conventional special education, which simply segregated children from their neurotypical peers and taught them general remedial subjects without any attempts to personalize the curricula. The 1987 study demonstrated that with intensive behavioral therapy, autistic children could learn socially acceptable language skills and behaviors relatively quickly compared to their peers who received conventional special education. A later follow-up study comparing one group that received 40 hours of therapy, one group that received 10 hours, and one group that received conventional special education demonstrated that almost half of the children who received the 40 hours of therapy were able to “lose” their autism diagnosis. Thus, ABA was born out of Lovaas’s work, with the goal of using intensive therapy to normalize autistic children’s behavior and allow them to be mainstreamed into educational settings with their neurotypical peers.
ABA was attractive to parents of autistic children, as previously autism was believed to be something of a psychological death sentence. Autistic children were simply shunted away into institutions, with the belief that nothing much could be done for them. ABA, however, offered an optimistic message that autism was not the end of a child’s hope for a socially normative life.
But it is this exact promise of so-called “normalcy” that renders ABA so controversial. Autistic people argue that ABA focuses too much on making autistic people more socially acceptable by having them unlearn stereotypical autistic behaviors. The emphasis on seeming less obviously autistic, especially when the children in question may not understand what this label means at the time, contributes to an internalized sense of stigma surrounding autism.
The idea that being autistic is a source of shame and stigma is antithetical to modern views of autism, particularly within the autistic community. The Autistic Self Advocacy Network’s position statement on disability rights states that autism is indeed a disability, but that “disability is a natural part of human diversity.” They argue for autism being viewed not as a source of shame in need of cure, as Lovaas saw it, but as a part of human diversity. The same way having different hair colors or eye colors is just part of human physical diversity, so too is autism just a form of neurodiversity. Thus, autistic people argue that ABA unfairly paints autism as something to be normalized out of children, a source of shame, when in fact autism should be viewed as part of the human experience.
Another critique of ABA is that it is inherently cruel. One mother whose son began receiving ABA at the age of 2 recalled how her child would “hysterically cry” during sessions, to the point that she would have to leave the room and turn on a sink to drown out her son’s tears to cope. The repetitive nature of ABA, in which children are required to practice a skill such as eye contact or introducing oneself endlessly until mastery is achieved, can be frustrating for even neurotypical children, let alone an autistic child who may have difficulty regulating or expressing emotions. Driving children to such extreme emotional reactions simply to make them seem less autistic is understandably a difficult idea for many parents to support.
Additionally, ABA often uses negative reinforcement to prevent children from stimming – that is, performing repetitive behaviors such as flapping their hands or rocking. Yet these stimming behaviors, while odd to neurotypical observers, help autistic people calm or soothe themselves, as well as find beauty and joy in a world made for neurotypical brains. To train autistic children out of one of the few self-regulatory mechanisms they have is to deprive them of comfort, a method of self-soothing, and even a form of emotional independence.
Lastly, many criticize ABA for not really achieving its stated goals of helping children gain ostensibly normal social skills. Instead, it focuses on small skills like holding eye contact for five seconds, skills that may not even be possessed by neurotypical people or that are not particularly socially relevant. As one former ABA practitioner said, “The last time I looked someone in the eye for five consecutive seconds, I proposed.” It also teaches the children these skills in isolation, without explaining the contexts in which they are used. One parent described how her son often asks strangers how they are doing, but then will walk away before they answer, simply because he’s been taught this is a good question to ask new people. Thus, while ABA may teach superficial social and language skills, it does not necessarily improve children’s ability to meaningfully socialize.
Despite these critiques, ABA is enormously popular and remains the leading therapy for autism. Parents credit ABA with helping their children communicate and allowing their children to attend school and summer camp. There is no doubt that ABA can be a useful tool for helping autistic children learn to communicate and even thrive. But ABA can also violate principles of nonmaleficence and justice, as it unjustly tries to force autistic children into normalcy by teaching them superficial skills in an emotionally taxing manner and may even take away some of their emotional regulation tools. It is this exact conflict between ABA’s beneficial effects and popularity and its ethical drawbacks that arouses mixed feelings in parents. While some parents completely refuse to use ABA, and others view it as the ideal therapy for their children, there are many parents who straddle the line between the two perspectives. One mother worries that ABA may be damaging and turning her son into what she terms a “robot,” yet still has her child in an ABA-based school because she wants “to do the best [she] can” and has found that “this is what works for him.”
Clearly, ABA does indeed work. But because of its potentially harmful methodologies and messages, ABA should no longer be considered the sole or definitive behavioral therapy for autism. Rather, parents who are trying to do the best they can for their children should demand better, more intensive research into alternative methodologies to manage autism.