Leaf, J. B., Cihon, J. H., Leaf, R., McEachin, J., Liu, N., Russell, N., Unumb, L., Shapiro, S., & Khosrowshahi, D. (2022). Concerns about ABA-based intervention: An evaluation and recommendations. Journal of Autism and Developmental Disorders. 52(6), 2838-2853. https://doi.org/10.1007/s10803-021-05137-y

Reviewed by: Caroline Simard, MS, BCBA & David Celiberti, PhD, BCBA-D
Association for Science in Autism Treatment

A Review of Concerns About ABA-Based Intervention: An Evaluation and Recommendations

Photographed by SHVETS (pexels.com)

Despite the substantial body of research supporting Applied Behavior Analysis (ABA) based interventions and their recognition as the most effective treatment options for autistics/individuals with autism spectrum disorder (ASD), it is not uncommon to hear concerns over their use. This recent article by Leaf et al., examines some of the most prevalent concerns and criticisms associated with ABA-based interventions. The authors are not only behavior analysts, but also psychologists, parents, and autistics/individuals with ASD, who are in a unique position to speak about concerns with the interventions used in ABA. The authors carefully and transparently elaborate on the reasons why some have taken an anti-ABA stance and acknowledge that although some concerns are valid, some are guided by misunderstandings and misconceptions of the goals of ABA-based interventions, or misinformation on the procedures that are currently and frequently utilized. The information shared in this article helps readers better understand why our evolving field has faced some challenges, which include the complex history and development of ABA-based interventions and procedures used to support autistics/individuals with autism, claims of possible negative side effects or harm, as well as what may appear to be less than optimal selection of goals, just to name a few. The concerns presented by the authors are broken down into the following five sections which we have used to summarize their important points and to supplement with additional recommendations.

Concerns over Lovaas’ UCLA Young Autism Project (YAP) are presented, which include background about this groundbreaking project, an important reminder of the landscape of autism treatment at that time, and clarification regarding such concerns as the use of shock, as well as the intensity, perceived rigidity, and formulaic nature of the intervention.

Some of the recommendations shared by the authors regarding concerns over the YAP include ensuring behavior analysts thoroughly understand the history of our field, explore past research, and recognize the need to continue to evolve our procedures as well as advocate for positive reinforcement-based contingencies. It is also suggested that the intensity of services should be individualized for each learner rather than prescribing a standard amount of service hours.

With respect to the concerns above, we certainly agree with the authors that we acknowledge the concerns associated with Lovaas’s early work. We would add that it would also be constructive to discuss with colleagues, students, and consumers that practically every helping discipline has experienced growth, improvement, and refinement over a 50-year period. For instance, pediatric oncology is quite different today than it was in the 1970s. Just as it would be inaccurate to critique present day pediatric oncology from the lenses of the 1970s, it is also important for critics of ABA to be measured when levying criticism for practices that are no longer practiced as they once were or perhaps no longer practiced at all.

Treatment intensity is certainly an area warranting more attention and research as it can aid in addressing some questions about which children with what characteristics would benefit from how many hours of intervention. Typically, intensity is described as a prescribed number of hours per week rather than the content, foci, or priorities of that intervention. To be frank, we are also surrounded by numerous examples of less individualized interventions. Here in the United States, every student at a public-school attends school for the same number of hours for the same number of days (e.g., 180 days). Many individuals receiving Amoxicillin for strep throat receive a standard dose (e.g., 100 mgs three times per day for 7 days). Of course, there are numerous cases of individualized prescriptions, but the important point is that we do see service providers often lean on standardized dosing.

This segues well into the matter of individualization as this guides every aspect of behavior-analytic intervention. These include, but are not limited to:

    • which skills are taught as per client and family preferences, needs, capacities;
    • how skills are targeted;
    • how data are collected and used;
    • how social validation is incorporated;
    • what types of prompting strategies are used;
    • how are motivators incorporated and faded; and
    • how generalization and maintenance is planned, promoted, and assessed.

When discussing our work as behavior analysts, it is important that we are transparent and explicit about the multitude of ways in which our interventions are individualized. All these efforts are woven into the fabric or our current Ethical Code (Behavior Analyst Certification Board, 2020).

Punishment and Extinction based procedures. The authors carefully remind the readers that it’s critical to understand the definition of punishment from a behavior analytic perspective, in addition to the history and the research supporting the most effective use of these procedures in accordance with our ethics. They discuss potential side effects reported in the research such as aggression and extinction bursts, and clearly state that more research is needed in this area to better understand potential side effects compared to other viable procedures. The necessity to assess situations where punishment may be necessary, ensuring we prevent the misuse of punishment and again, using reinforcement-based strategies as alternatives whenever possible, are also topics that were discussed in this article. The readers also learn about some concerns that have been voiced regarding possible trauma related to the use of such procedures, research supporting their use, and a call for future research.

Our continually evolving ethical code has addressed the use of punishment with increasingly more precise language and standards. More specifically, 2.15 Minimizing Risk of Behavior-Change Interventions of the Ethics Code for Behavior Analysts (BACB, 2020) clearly states that punishment-based procedures should be considered and used only after less intrusive means and the risk of harm for not considering such, exceeds the potential risk associated with the punishment-based procedures themselves. The commitment to data-based decision-making that appears throughout the Ethics Code is referenced explicitly in this section as well.

In terms of recommendations in this area, the authors encourage engagement in meaningful discussions with various stakeholders, where information is shared on our procedures and how they can help with individualized and socially significant goals. These discussions could lead to further development of guidelines around the use of these procedures and could in turn help enhance the code of conduct/ethics that Behavior Analysts must abide by. It is also suggested to avoid blanket statements about eliminating all punishment-based procedures, as this would not necessarily align with the research or naturally occurring contingencies in the environment. In fact, we would recommend that discussions of punishment include reference to the many ways it manifests in our day-to-day lives (e.g., late fees, speeding tickets, poor product ratings) and the potential impact it can have on shaping behavior.

Self-Stimulatory and Stereotypic Behavior. Another criticism that has been voiced by autistics/individuals with ASD and individuals supporting neurodiversity activists are claims that ABA-based interventions to reduce or eliminate stereotypic behaviors are problematic for several reasons (i.e., not considering why the individual engages in the behaviors, the need for society to be more accepting of these behaviors, and their reduction could be considered abusive). The authors remind us of the importance of promoting inclusivity, and by providing choices and opportunities, we have an obligation to ensure we are best preparing those we support for success, which may at times include the need to reduce or eliminate self-stimulatory/stereotypic behaviors that could be stigmatizing, create barriers, or limit access.

Further recommendations put forth by the authors include always ensuring that claims of abuse are taken seriously, actions taken as needed (i.e., reporting), and a statement that more research around social validity in this area could help us assess which self-stimulatory/stereotypic behaviors could have negative impacts/interfere with employment, and opportunities to fully participate in society.

In addition to the authors’ recommendations, we would also add that it would be important to assess whether stereotypic behaviors are maintained by positive or negative reinforcement (in other words, is it a “like” or a “need”). This distinction would be very beneficial in determining how best to address, in how to frame the discussion with clients and their families, and what alternative responses can be considered (Sundberg & Celiberti, 2015). Finally, this important topic provides us with many wonderful opportunities to teach autistic individuals how to recognize their sensory needs and preferences and to develop the requisite skills to self-advocate that can run the gamut from modifying their own environments to enlisting others in supporting them in various challenging situations and conditions.

Goal Selection and the Goals of Therapy. Additional concerns voiced over the years include claims that individuals supported are not part of goal selection, the goals selected are not appropriate, or that the goals will lead to changes in the individual’s personality. The authors remind the readers of the critical importance of social validity, a hallmark of the field of ABA for decades, stated clearly by the pioneers of our field, and is now included in our codes of conduct (e.g., Huntington et al., 2022; Wolf, 1978). There is no doubt of the importance of including autistics/individuals with ASD in the selection of goals whenever possible, as well as the need to share research regarding social validity measures of our interventions. The authors eloquently share with the readers how Skinner (1974) described personality as “at best a repertoire of behavior imparted by an organized set of contingencies” (p.164). Most importantly, the goals of ABA–based interventions are to help its recipients to develop repertoires that will empower them and increase options and opportunities. We are in the business of helping people…helping people learn how to learn and trying our best to improve people’s quality of life by teaching socially significant skills.

In this critical area where concerns need to be understood and addressed, the authors propose the following recommendations:

    1. Ensure that the individual is included in the goal selection process whenever possible; it should be a collaborative process with a thorough understanding of the importance of the selected goals by everyone involved.
    2. The authors also highlight the importance of listening to others’ concerns, having meaningful and transparent discussions around goal selection and their social significance, and as needed, referring to other service providers for their input, particularly when outside of the scope of practice and competence.
    3. The authors also share the need for increased research in social validity and that training in meaningful goal selection is paramount for behavior analysts.

Abuse and Long-Term Negative Outcomes. A final but critically important concern shared in this article are claims that ABA-based interventions and procedures are abusive and can lead to serious negative outcomes (i.e., depression, anxiety, post-traumatic stress disorder). As stated earlier, the authors do believe that all claims of abuse should be taken seriously and remind behavior analysts of the importance of familiarizing themselves with research in this area. The authors share two helpful examples of peer reviewed publications related to these claims, however notable are the limitations of the studies, such as the absence of replications, and poor reliability.

Recommendations that could address the concerns regarding claims of abuse and long-term negative outcomes include ensuring that those working in our field listen to those with lived experiences and continue to be compassionate but also remain cautiously skeptical. More research that is carefully and ethically conducted is also warranted in this area and will lead to better assessments of possible risks and factors that could influence recommendations for specific ABA-based procedures. According to the authors, it also remains critical to report and share broadly the positive results of our interventions and that the development and expansion of the body of research around outcomes and quality of life measures will provide clarity and inform any large-scale changes to our field and its interventions.

Despite the empirical support for ABA-based interventions, there are still concerns being shared by many. Leaf et al., encourage further evaluations and discussions of these concerns within peer reviewed literature. The goal of our science is to improve the quality of life of those to whom we provide services to increase their options by teaching skills in various domains and by decreasing the frequency of behaviors that interfere with their ability to learn and to fully participate in society.

In Summary

The authors tackle these sensitive and important topics in a transparent, honest, and informative manner, providing helpful references, accurate details, and most importantly, providing valuable recommendations that can help our field move forward productively to best support others. In fact, this article should be required reading for graduate students pursuing a degree or certification in behavior analysis. We are lucky that our field continues to evolve; and to assess its effectiveness and the social validity of its goals and interventions, however, there is still progress to be made. We have a responsibility to listen to concerns, to engage in collaborative and transparent discussions with those we support, and all stakeholders involved, and we should avoid invalidating those who may view our procedures negatively or what we may perceive to be inaccurate.

We can and should learn from others, including service providers who also have the goal of improving the quality of life of individuals they support and parents who want the best for their children. Most importantly, the ability to have honest and open discussions combined with the decades of solid empirical evidence for the interventions used in ABA, puts us in a unique position to move our field forward and make any necessary improvements. If there are areas in which we can improve, we must rise to that occasion.

If we have an opportunity to improve the procedures that guide our interventions, to be more compassionate, and to better understand how those receiving our services feel about our interventions, we owe it to them and to our field. It’s worth our time and effort to carefully evaluate and assess the goals of our interventions.

All those using ABA-based interventions and supporting those living with ASD should be familiar with the information presented in Concerns about ABA-based intervention: An evaluation and recommendations. We must not shy away from the history of the interventions we use or from having transparent and productive discussions. We must also continue to assess the procedures used in ABA-based intervention to support autistics/individuals with ASD.

References:

 Behavior Analyst Certification Board. (2020). Ethics code for behavior analysts. https://bacb.com/wp-content/ethics-code-for-behavior-analysts/

Huntington R. N., Badgett, N. M., Rosenberg, N. E., Greeny, K., Bravo, A., Bristol, R.M., Byun, Y. H., Park, M. S. (2022). Social validity in behavioral research: A selective review. Perspectives on Behavioral Science, 46(1), 201-215. https://doi.org/10.1007/s40614-022-00364-9

 Skinner, B. F. (1974). About Behaviorism. New York: Random House.

 Sundberg, C., & Celiberti, D. (2015). Clinical corner: Is a BCBA the right person to help with my child’s sensory issues? Science in Autism Treatment, 12(2), 11-15.

 Wolf, M (1978). Social validity: The case for subjective measurement of how applied behavior analysis is finding its heart. Journal of Applied Behavior Analysis, 11(2), 203-214.

Citation for this Article:

 Simard, C., & Celiberti, D. (2024). Review of Concerns about ABA-based intervention: An evaluation and recommendations. Science in Autism Treatment, 21(03).

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