ABA and Company – Traumatic Therapies

One of the greatest concerns to adults within the autistic community – both autistic people, and parents who have experience and have seen the consequences – is how consistently the medical / health system promotes therapies for autistic children such as Applied Behaviour Analysis (ABA). And while many practitioners will claim there are crucial and marked differences, many other therapies follow a similar approach, including: 

• Positive Behaviour Support (PBS)
• Early Intensive Behavioural Intervention (EIBI)
• Intensive Behavioural Intervention (IBI)
• Early Start Denver Model (ESDM)
• Positive Behavioural Interventions and Supports (PBIS)

What Are They?

These therapies all tend to engage a child in an activity, model a way of doing it, and reward the child modifying their behaviour to match. The intention is to increase functional skills, and reduce behaviours that are seen as problematic. Sounds fine, right?

Are They Entirely Bad?

The difficult thing here is that, no, not everything about these therapies is bad. Many of the behaviours and skills modelled can be beneficial if adopted for genuine reasons (rather than due to positive reinforcement); that would be education. Teaching autistic kids new skills is great. Demonstrating behaviours they might choose to adopt for whatever reason is helpful. Showing them what neurotypical people might choose to do can be useful information.

So it’s not a case of saying that there is nothing to be gained from any of these therapies. Or that it’s impossible to deliver some elements of them in a neuroaffirming manner. Or that all therapists who deliver these therapies are awful people, rather than uninformed or unaware.

However the basic premise, and the end goals, cannot be perceived as nurturing or neuroaffirming.

What’s Wrong with These Therapies?

While they are positioned as a means of teaching autistic kids skills that will allow them to thrive in a neuronormative society, it doesn’t stop with educating. It promotes neuronormativity as the right way to do things, discourages presentations that are typical to autistic kids (even if they’re not harmful to self or others, just different), and rewards the child for doing things the way the clinician wants them to.

Frequently, children are punished (from a “No”, through to the clinician stonewalling them or erasing/changing the child’s work) for natural behaviours. Sometimes the latter is used as a “lesson” in itself. For example, a child might be encouraged to drive toy cars around the floor instead of lining them up in size order. The clinician will mess up the child’s array, and then use positive reinforcement if the child doesn’t demonstrate distress about this.

Applied Behavior Analysis (ABA) practices will always be based upon a foundation of compliance, coercion, and behaviorist principles.

It is impossible to practice ABA even gently or playfully, without attempting to control and manipulate a person’s behavior. The fundamental goal of ABA is compliance with the will of the person in the position of authority, which counters self-determination, undermines self-advocacy efforts, and infringes on human dignity and fundamental human rights.

– Why Not Positive Behavior Support (PBS), Positive Behavioral Interventions And Supports (PBIS), Or Positive Reinforcement: https://therapistndc.org/positive-behavior-support-pbs-positive-behavioral-interventions-and-supports-pbis-or-positive-reinforcement/

Long Term Effects

While many parents have reported “great results” from these therapies, the measures are dubious. A child who conforms, behaves as hoped more often, acts like “other kids”… But at what cost?

Sensory

Learning not to stim using these therapies does not remove an autistic person’s need to stim. Nor does it replace this need with an alternative. It simply reinforces that stimming is the wrong thing to do, and rewards the ability to avoid it. 

They are giving children stickers, praise, attention, connection, encouragement, inclusion, and other positives, for learning to tolerate psychological and physiological discomfort or even torment.

They are teaching them that other people’s socially-learned discomfort at a child moving in a way that isn’t the way neurotypical people move is more important to repair than the genuine hurt felt by someone denying their own sensory needs.

Trauma

There is a high incidence of Post Traumatic Stress Disorder (PTSD) in autistic adults, and research indicates that those who were subjected to ABA are 86% more likely to experience PTSD than those who weren’t.

A lifetime of being punished for certain movements, and being forced to engage in eye contact despite the physiological pain and discomfort of doing so, is psychological and physical abuse.“

– Sandoval-Norton and Shkedy 2019

Skills Development

As mentioned above, ABA-style therapies generally do not redirect needs. Instead they encourage children to suppress them (with the incorrect inference that this means they no longer exist!). 

Sometimes aspects of being autistic, particularly presentations of distress, do need to be amended if possible for the benefit of self and others. If you can prevent your child from smacking their head on the floor when they’re upset, should you? Yes! Should this involve them simply sucking up that distress and not “inflicting” it on others? No. Does it mean teaching them skills such as Dialectical Behaviour Therapy (DBT), redirecting these feelings into safer behaviours, offering coregulation and support? Yes.

Not only does this process teach autistic kids that there are methods that are safer, more soothing, and less risky to their bodies, self-esteem, and people around them… it teaches them that there are often alternative options if there’s something about their lives they’re finding difficult. And more importantly, it gives them the positive experience of learning new positive skills.

By simply rewarding a child for mimicking and suppressing, clinicians are missing a valuable opportunity to empower these kids by teaching them how to self-advocate, adapt, and learn things that make them happy.

Self Esteem / Minimising Importance

Whether it’s a conscious awareness or otherwise, these children are humans who’ve been repeatedly told their way of doing things is wrong. Their parents have paid someone to force them to be someone other than themselves. They’ve been rewarded for choosing self-inflicted pain over authenticity. Self-esteem is decimated.

The enthusiasm for sharing information about their favourite topic? Gone. Because they’ve been taught to rein it in because “other people aren’t interested”. But when all their peers are obsessed with the same band and talk about it frequently? That’s fine. Their own passions, interests, glimmers, and happiness, is minimised unless it conforms to the majority.

Behavioural Contrast AKA You’re Never Good Enough

Behavioural contrast is a common presentation in any child experiencing behavioural “training”, where one area appears to improve but another becomes problematic.

This is often seen in autistic kids who mask heavily at school, then experience the Coke Bottle Effect when they get home.

While this is a frustrating experience for both the child and their parents, what it communicates to the child over time is that they’re never good enough. That no matter how hard they work to meet other people’s needs in one area, and how much they suffer as a result, if that suffering shows its face elsewhere then they’ve still failed.

Encouraging masking, chameleon-behaviours, or suppression of needs is exhausting, traumatic, and unsustainable without causing other difficulties.

Grooming and Abusive Relationships 

Remove the context of autism.

What do you think would happen to a child who receives early intervention therapies that effectively teach them that if they do what they’re told, meet someone else’s needs and preferences, and behave in a way that doesn’t come naturally, they will receive things they want? And that if they resist, and try to be authentic, they will be deprived of the good things (at best! Some forms of ABA actively “punish” a lack of compliance)?

You’re building humans who are pre-programmed to be manipulated. To accept abusive behaviours in relationships in order to receive “love”. To tolerate unacceptable treatment in all environments including friendships, work, and healthcare.

It sounds like a pretty extreme analogy, but if these kids weren’t autistic, many would consider it a precursor to grooming. A lot of the behaviours seen in predators follow the same pattern: get attention, seem engaging and appealing, act invested in the child’s interests, then tell them what they need to do – even if they’re not comfortable with it, reward them when they do, and correct/criticise/ostracise if they don’t.

Should We Skip Therapy Then?

Absolutely not! If your child would benefit from therapies, that is what they are there for. But it is crucial to think about why you’re pursuing therapies, and what you want to achieve.

For example:

• Do you want your child to stop biting themselves and causing injuries? Sounds like a great reason to invest in therapies that will help them adopt more soothing behaviours, learn emotional regulation and self-advocacy, and find out how to prevent reaching that level of dysregulation. And it would be a great opportunity for you to look into therapies that would teach you coregulation and similar supportive approaches.
• Do you want your child to stop needing to stim? For many people with sensory differences, that’s not an option; you’d still need to redirect this need and fulfil it in another way. 
• Do you want your child to stop stimming so people don’t stare at them? Have you asked your child about this first? If the discomfort theirs, or yours and society’s?
• Do you want you child to stop stimming because you find it irritating? Ideally, you would consider DBT or something similar for yourself, learning neuroaffirming approaches, and challenging your ableism.

Helping your child achieve their goals, meet their needs in the safest and easiest ways possible, and express themselves, is key.

If you want some assistance discerning which supports are neuroaffirming (especially when so many claim to be), and which therapies might support and empower your child rather than squash and traumatise them, please reach out.