15
criticisms of Applied Behavioural Analysis approaches
For
many years now, I have heard several criticisms of the use of ABA approaches to
working with children and young people with autism. The typical response from
supporters of ABA approaches is to say that these criticisms are ill-informed,
incorrect, or relate to the vested interests of the proponents of other
approaches who cannot identify strong evidence for their own interventions. In
this blog, my aim is instead to take each criticism (gathered from a number of
sources – special thanks to those who contributed to the list!) and provide a
perspective on them. The reason for taking this approach is that criticisms may
well have come from people’s direct bad experiences, or from secondhand reports
of poor practice. Thus, these points do have to be addressed.
I
need to make several points before I begin:
·
I
am no spokesperson for ABA. I do hope that I understand the ABA field to some
extent but also much more broadly autism, intellectual disability, families,
and education. Thus, I am trying to use all of these perspectives to reflect on
common criticisms of ABA. However, it is in no sense an “official” response.
·
I
am also not writing this for experts in ABA, although I do hope that ABA
practitioners will find my observations helpful. In any case, I will not
attempt to be technically accurate at all points. Instead, I am trying to
explain things for a wider audience.
·
Several
of the criticisms that I will deal with below are more generally about poor practice
and are not specific to ABA. Thus, there is certainly a need to improve the
quality of practice across the board when it comes to working with children and
young people with autism.
·
Many
relevant points have already been addressed in earlier blogs of mine. I will do
my best to refer back to those blogs at appropriate points – so that people can
read a fuller treatment of the issues. However, I would encourage everyone to
read the whole series of blogs on autism and evidence.
1. ABA
has a “normalizing” agenda
The
criticisms here focus on a number of related points. The first is that ABA
approaches are focused on taking away something of the child’s autism – trying
to make the child “normal” in some way. Critics argue that this also leads to
proponents of ABA approaches trying to convince parents and others that they
can “cure” a child of autism, or more generally that “ABA can lead to recovery”
from autism. A second area of criticism is that ABA focuses on
reducing/removing behaviours that cause no harm for the child and in fact are
functional for them (especially stimulatory behaviours – “stims”).
Some
discussion of this issue can be found in two of my previous blogs, so please
take a look at those first:
In
summary, ABA approaches in autism do not “decide” which behaviours to focus on
in terms of developing new skills or reducing existing problematic behaviours.
Multiple perspectives are used to identify targets for intervention including
the child, their family, teachers etc. Ethically speaking, behaviours ought to
be the target for reduction only when suitable alternatives are available for
children (and these may have to be taught), and when the behaviour in question
is clearly interfering with an aspect of the child or family’s experience of
quality of life. Sometimes, “stims” may be targeted for reduction for these
reasons, but there is no prescription to do so as a part of an ABA programme.
When
it comes to a broader normalizing agenda, this is an issue that is not specific
to ABA. In fact, educationally focused interventions in general ought to be
about making a positive difference and not succumbing to a medical model agenda
of cure or recovery.
That
said, unfortunately, it is true that some proponents of ABA sell their services
on the basis that recovery “is possible”. Thus, many people may have heard
these qualified promises, or perhaps stronger promises made. However,
proponents of many other interventions in autism also make similar (sometimes
much stronger) claims. The fact is that many interventions exist within a
marketplace where they are trying to attract attention of parents as
“consumers”. Until autism organizations and government bodies recommend (and
fund) only interventions with a clearly demonstrated evidence base, this
marketplace will continue to function.
An
important point to make is that just because some individuals or organizations
argue that ABA can lead to some sort of recovery from autism does not mean that
this is what ABA is all about.
2. Children
fail to generalize skills
Under
this general heading of criticisms are perhaps two related points. First,
children become dependent on one-to-one teaching, or learning in particular
contexts only. Second, one-to-one teaching does not encourage independence.
A
defining feature of interventions that can be called Applied Behavioural
Analysis is that they directly address generalization of learning (to new
teachers, settings, and skills) and also the maintenance of newly acquired
skills in the child’s typical environment. It can be hard to establish
generalization for children with autism whatever intervention approach you
chose. However, ABA includes a variety of methods and perspectives to directly
teach generalization of skills. If a child on an ABA intervention has not yet
generalized their new skills, the programme or intervention is not yet
completed.
I can
imagine that people will have seen children reported to be on ABA programmes
who are currently failing to generalize their skills. However, this is most
likely a feature either of where the child has got to (generalization is still
being worked on), or perhaps a reflection of the lack of competence/experience
in their intervention team. In neither case is the failure to generalize an
inherent feature of ABA.
In
fact, quite the opposite. ABA approaches explicitly recognize the need to teach
and establish generalization, and (unlike many other intervention approaches)
practitioners have worked for many years to establish methods of teaching to
maximize generalization. Some of these methods will still rely on one-to-one
teaching. It is not one-to-one teaching that causes problems in terms of
generalization, but the failure to properly plan for and teach generalization
causes generalization problems!
3. ABA
is adult led
I
think this criticism focuses on the experience of ABA programmes for children
with autism where a teacher (therapist, tutor) presents as many learning
opportunities to the child as possible. Although an adult will also incorporate
natural learning opportunities (see below), the adult can perhaps be seen as
the main active participant in the intervention. My understanding of this
criticism is also that the implication is that this active involvement of an
adult teacher is somehow “bad”. So, perhaps one reflection on this criticism is
to ask why that might be a bad thing. The alternative might be to offer very
little by way of teaching support to children with autism who may just not
interact with other people much at all.
A
more positive perspective is to clarify that ABA interventions are very clearly
child focused and individualized. Thus, initial targets for intervention are
defined by young people themselves, their families/carers/advocates, and the
expectations of society. Delivery of an ABA programme also focuses on the
hour-by-hour collection of data about the child’s learning. Thus, bespoke
evaluation is used. In addition, reinforcers (in common language often called
“rewards” – also see below) are chosen for the fact that they can be used to
motivate an individual child (through a formal process of reinforcer
assessment). Also, ABA programmes begin with a very detailed individual
assessment of the child’s strengths and weaknesses that informs what should be
taught first and what might follow once foundational skills are established.
So,
depending on what critics mean by “adult led” perhaps ABA interventions can be
described in this way. However, they are also child centred and individualized
at multiple levels.
4. ABA
is rigid and reduces the opportunity to respond naturally to spontaneous
initiations and interactions with the child
This
may lead on from the previous criticism about being adult led. Any high quality
ABA programme will, however, incorporate learning opportunities within the
typical environment. Some approaches major on this approach – natural
environment teaching/training is a widely applied method. All high quality ABA
programmes will also take advantage of learning opportunities outside of formal
teaching sessions. This is one reason why family members are often encouraged
to be involved in a child’s programme – so that they can help with the
maintenance of the child’s learning within their day-to-day environment.
Perhaps
the error is to focus only on one part of ABA intervention approaches – the
more formal and typically table-top delivered Discrete Trial Training method.
For me, DTT is about direct teaching of new skills that are practiced so that
the child becomes fluent in the skill within the teaching environment. Next
steps are obviously to extend these new skills to other settings and to ensure
that the skills can be maintained in the child’s everyday environment (generalization
and maintenance again). Unless a child becomes fluent in a skill, it is hard to
achieve long lasting intervention effects. This is an error in some other
intervention approaches where it is not clear if a child truly masters a skill,
and the likelihood of successful generalization and maintenance is likely
reduced.
So,
perhaps DTT might look “rigid” to an outside observer not looking at the whole
context of a child’s programme. I would also be concerned if a child’s
programme only consisted of DTT because it seems unlikely that proper attention
is being paid to generalization and maintenance of skills. Thus, “rigidity” may
be serving an important purpose within ABA programmes, but ongoing reliance on
DTT especially later on in a child’s programme MAY be an indication of poor
practice. Thus, ABA isn’t rigid but it may be applied in lower quality
programmes in a more rigid manner.
5. Reliance
on “external rewards”
There
is a collection of criticisms that seem to me to focus on the idea that ABA interventions
somehow force a child to learn. Children are offered “rewards” to
perform/behave in certain ways and so this is not real learning – the children
are not learning real skills. A related criticism is that ABA interventions
make the child too reliant on the structure of the intervention and so they do
not learn to occupy themselves.
These
points touch on the motivation to learn. I cannot see how a child can be forced
to learn. It is certainly the case that skilled ABA practitioners are very good
at motivating a child to engage with learning. The reason that reinforcers are
applied in the context of ABA interventions is because basic research on
learning demonstrates that we learn through the gradual shaping through
reinforcement of successful ways of behaving. New skills, once learned to a
fluent level, “self-maintain” because they lead to success in the child’s
environment. The whole process of generalization and maintenance (see above) is
all about “real” learning and long term change in behaviour.
Why
do children with autism often have to be taught using “rewards” delivered
reliably by a teacher in the context of the intervention programme? Because
they have often failed to learn key skills by other means. Therefore, they need
to be taught these skills. The way to teach new skills is by the behavioural
teaching methods used in ABA interventions.
An
important outcome of any intervention, and ABA is no exception, is that a child
develops learning-to-learn skills. These skills can be taught like any other.
They might be examples of what ABA folk sometimes call pivotal skills or
behavioural cusps – skills that once learned open access to other learning
reliant on these building block skills. In addition, children can be taught
self-management skills. They can monitor/record their own learning and make
adjustments to their approach to learning based on this information.
6. Lack
of focus on sensory issues
Some
experts in the field of autism adhere to a position that sensory sensitivities
are a core feature of autism. In the new DSM definition of autism, such sensory
issues are to be more centrally represented. The implication seems to be that
any intervention for children with autism should include a piece that states
clearly how sensory issues are addressed.
Sensory
issues ARE special in ABA intervention but at a very individual level – there
is no one set of intervention supports that would be thought of as the “sensory
bits”. First, sensitivities to sensory information need to be understood to be
able to plan for how best to teach an individual child. Second, certain sensory
stimuli may have unusually aversive properties for a child with autism. This
would also be discovered in the context of a reinforcer assessment (how best to
motivate the child to learn, and by implication how not to motivate them!).
Third, on some occasions a child or young person may seek help to tolerate
sensory experiences that they struggle with in the service of a higher level
goal. For example, working in the film and television business may require
tolerance to bright lights. ABA methods can often be used to enable children
and young people with autism to develop tolerance to self-manage their sensory
sensitivities. Complete avoidance is often not an option for those who wish for
inclusion in society and independent living.
7. The
speech children produce when on an ABA programme isn’t “real”
This
criticism is that ABA practitioners do not work on the precursors to language
skills first when they teach children to speak. However, my understanding would
be that any good quality ABA intervention would be developmentally informed. A
good understanding of typical development is needed to inform which skills to
teach in steps towards a more complex skill and in what order these steps
should be taught. The most important issue is also that language is functional
– that the child can use it to obtain what they want to obtain. Thus, the real
test of whether good skills have been taught is whether they work in the
child’s environment.
Speech
production itself is also probably a good example of an area of knowledge where
other professionals are expert and could be collaborating with those who know
best how to teach children complex skills (ABA practitioners).
8. ABA
is a one size fits all approach
ABA
is a child centred and individualized approach as described at several points
in generating answers to other common criticisms, and in my earlier blogs. What
is taught and how this is done, will vary depending on the child’s strengths
and weaknesses, theirs and their parents’ wishes, and how quickly they learn
the skills.
In
thinking about this criticism, which just doesn’t make sense to me given my
opening comments, I suspect that it may come from seeing practitioners at work
who aren’t yet experts. In all areas of practice, experts are those so fluent
in an intervention approach that they know the theory and practice inside out
and can problem solve quickly and effectively as they go along. Thus, they are
very good at responding to individual variations and creating new ways of
supporting individuals where the intervention isn’t quite working. This is no
different for ABA practitioners. Early on in people’s development, there is
likely to be a reliance on using manualised approaches and perhaps ABA
programmes may look quite similar across different children. Things will look
very different when you watch a real expert at work.
Again,
my point is that “one size fits all” is not a feature of ABA intervention per
se. Rather, it is perhaps an indication of inexpert delivery of any
intervention approach. At heart, ABA is much more of an individualized approach
to intervention.
9. Use
of punishment
Several
critics point to the use of punishment in ABA programmes historically and also
very rare cases internationally of services calling themselves ABA and using
electric shock, amongst other things.
Punishment
is not a process that leads to the learning of new behaviour, but it can be
used to stop children engaging in challenging behaviours that may be dangerous
to themselves or others. The use of punishment is outlawed or very heavily
restricted in codes of ethics and professional practice in the field of ABA
generally (as it is by all professional bodies) and so also in ABA
interventions applied to children with autism.
ABA
practitioners are also trained to a much higher level than other practitioners
to recognize and understand punishment so that they can avoid its unethical
application. This is actually quite a technical point. What most people mean
when they talk about punishment is either degrading practices (which must be
outlawed on an ethical basis), or things that many people find aversive.
Punishment in ABA is different in the second respect because what is aversive
is known to be very individual (just like the things that positively motivate
each child). In addition, “punishers” are defined by their effects on
behaviour. Most typically, if something happens after a child’s behaviour that
leads to that behaviour being less likely to occur in similar situations in
future, that “something” is acting as a punisher.
In
summary, modern ABA programmes and practitioners do not use punishment.
Practices agreed to be degrading are outlawed. At the same time, ABA
practitioners have a clearly developed understanding of what punishment
actually is and how individual it is. Thus, they should be less likely than
other practitioners to punish a child’s behaviour. Without a nuanced
understanding of punishment, other practitioners may be inadvertently punishing
a child’s behaviour. This is a potentially serious issue in practice.
10. Lack
of professionalism amongst ABA practitioners
For
me, this is an area again where a category error is being made by critics.
Thus, behaviour that may be considered less than professional that they might
observe in some ABA practitioners is somehow attributed to the approach per se
rather than to the individuals concerned, or the system in which they work.
Common criticisms include that the qualifications of ABA staff are not clear,
little attention is paid (in the UK) to the National Curriculum, and ABA staff
will not collaborate with other professionals in school settings.
Putting
it very simply, ABA interventions do not require practitioners to be
unprofessional.
That said,
there are very important questions to be asked about how ABA interventions
should be best governed at least within the UK education system. Because local
education authorities have typically failed to invest in ABA-based services,
the ABA interventions that they have funded have historically been as a result
of parental demand and even parents seeking legal redress to get funding for
their child’s ABA programme. Thus, education authorities have been reactive
rather than proactive. This means that the staff with the ABA skills are often
outside of the system. And, Yes, this can mean that people are employed to work
on ABA programmes who lack a broader professional training (despite the fact
that they may be very good at directly teaching children).
My argument
would be that the UK education system must properly engage with ABA practice
and work out how to make the benefits available to as many children with autism
(and other special educational needs) as possible. The ABA community in the UK
has carried out a piece of collaborative work to address professional standards
including clarity about the range of competencies that high quality
practitioners should be able to demonstrate. The UK ABA Autism Competencies
Project focused on ABA competencies but also competencies relating to autism,
working professionally, and working within the four countries of the UK in the
education system (including the context of the National Curriculum).
My
message to local authorities – stop using perceived lack of professionalism in
ABA as an excuse for ignoring its benefits. Instead, engage with the ABA
practice community.
Follow
this link to the competencies framework for a free download of the full
information:
http://www.ambitiousaboutautism.org.uk/page/what_we_do/research/aba_competencies.cfm
11. ABA
programmes can be never-ending, and the long term benefits of ABA are not clear
Never
ending ABA programmes is a criticism that probably deserves a separate
discussion. In fact this is quite an interesting issue. The first is that this
criticism often comes from local education authorities in the UK who typically
fund the interventions. It is not clear why they haven’t got appropriate
governance in place to prevent extended early intervention programmes from
running. From families’ perspectives I can see why they would want to extend
funded intervention time for as long as they can. There may also be confusion
about what ABA intervention actually is (see http://profhastings.blogspot.co.uk/2012/12/autism-evidence-3-what-is-aba-for.html).
Many people confuse Early Intensive Behavioural Intervention with ABA more
generally. My own position is that running an EIBI model beyond early childhood
(i.e., when intervention would be “early”) is not appropriate, but ongoing use
of ABA teaching methods throughout life for a person with autism is a very good
idea.
Evidence-based
support shouldn’t end just because young people with autism move beyond early
childhood. However, I can also see that an unchanging ABA programme in
adolescence that still looks like the intervention the child was receiving at
3-4 years of age is unlikely to be sensible.
In
terms of long term benefits, it is the case that long term follow-up of
children who received ABA early intervention has not yet been the subject of
significant research effort. Thus, in that sense the long term outcomes of EIBI
as an early intervention are unknown. However, again, this is not unique to ABA
intervention. There are no significant similar data either for other autism
interventions. There is, however, international consensus about the value of
early intervention in autism and the notion of intervening early for longer
term impact on quality of life.
If
this “long term benefits” criticism relates to the value (or otherwise) of
extended ABA intervention, this point has been addressed above already.
12. ABA
is very American and doesn’t work for the UK education system
Both
of the major UK-based evaluation studies that I’ve been involved in as a
researcher have been carried out within the UK education system and in
collaboration with local education authorities. In SCAmP, we worked with 11
education authorities in Southern England to deliver and evaluate a home-based
EIBI model (Remington et al., 2007). In the Westwood School project, we worked
with two education authorities in North Wales and delivered and evaluated an
early years school based ABA model integrated into a mainstream school (Grindle
et al., 2012).
Both
studies reported positive results for the children with autism who received the
intervention. We certainly did have to work hard to develop a model that used
the best of ABA intervention evidence and delivered this appropriately within
the UK education system. However, all of the many people involved (children,
parents, teachers, education administrators, ABA practitioners, other
professionals, researchers) worked together to deliver the positive outcomes.
It can be done in the UK.
13. ABA
is too intensive and expensive
As I
have mentioned before in this blog series, I do not believe that ABA comes with
a prescription for intensity. International consensus, not “ABA”, suggests that
early intervention for autism should be intensive. There are some indications
that intensity of ABA intervention is associated with outcome. However,
intensity only explains a small amount of the variability in outcome in EIBI.
There are likely to be several other factors in play.
ABA
practitioners strive to deliver the best quality that they can with the
resources available. Resourcing decisions are ones that are made by education
authorities and other official bodies.
Those
points made, there are several examples of evaluation studies in the research
literature (e.g., Eldevik et al., 2012) suggesting that ABA interventions
produce better outcomes than eclectic special education funded at the same
level of cost. It seems that you can spend the same amount of money and still
get better outcomes.
14. ABA
is hard on family life and family members
I am
always interested to hear this criticism since our research group has been one
of the few worldwide to carry out research on this question. It is often
assumed that an intensive home-based intervention programme may be stressful
for parents and other children in the family. This assumption is unlikely to
apply to ABA programmes run primarily in school settings away from the home.
However, even in the home context the research data do not support the anecdotal
assumptions. Stress did not increase over time in parents whose children
received EIBI in the family home (Remington et al., 2007), parents of children
with autism on home programmes and siblings do not seem to have elevated levels
of psychological problems compared to other parents/siblings (Hastings &
Johnson, 2001; Hastings, 2003), and although parents did report that the
intervention can be stressful they would do it all again and strongly recommend
ABA to other families (Grindle et al., 2009).
15. ABA
is only for the “severe” children
A
final criticism that I will address at this point is one that ABA might be
useful only for those with severe autism and/or who have significant
challenging behaviours. Higher functioning children do not need ABA.
By
this point, I should ask you the reader to generate your own answer to this
criticism. My view is that again we are probably dealing here with a
mis-understanding about what ABA is. ABA teaching technologies are for all
children and young people – nothing to do with autism, and certainly nothing to
do with the severity of autism. Most children at some stage will require some
additional support to develop a new skill, manage problematic behaviour, or
extend their skills in an area where they are already expert. The
evidence-based way to teach children when they need this assistance is to use
methods informed by our understanding of learning theory. Perhaps this
criticism is linked to a mis-understanding that EIBI is the only ABA
intervention. I can certainly see that perhaps children with the highest levels
of need are the ones who may need a comprehensive early intervention programme
– teaching them across multiple skills domains. Children and young people with
more specific needs would still benefit from a focused ABA intervention dealing
with a particular domain of skill development (e.g., reading, numeracy, social
skills, managing anxiety).
Thank
you for reading, and sorry this ended up being so long – there was a lot to
say!!
References
to research studies mentioned above
Eldevik, S., Hastings, R. P.,
Jahr, E., & Hughes, J. C. (2012). Outcomes of behavioral intervention for
children with Autism in mainstream pre-school settings. Journal of Autism
and Developmental Disorders,
42,
210-220.
Grindle, C. F., Kovshoff, H.,
Hastings, R. P., & Remington, B. (2009). Parents’
experiences of home-based Applied Behavior Analysis programs for young children
with autism. Journal of Autism and Developmental Disorders, 39, 42-56.
Grindle, C. F., Hastings, R. P.,
Saville, M., Hughes, J. C., Huxley, K., Kovshoff, H., Griffith, G. M.,
Walker-Jones, E., Devonshire, K., & Remington, B. (2012). Outcomes of a behavioral education model for children with
autism in a
mainstream
school setting. Behavior Modification, 36, 298-319.
Hastings, R. P. (2003).
Behavioral adjustment of siblings of children with autism engaged in applied
behavior analysis early intervention programs: The moderating role of social
support. Journal of Autism and Developmental Disorders, 33, 141-150.
Hastings, R. P., &
Johnson, E. (2001).
Stress in UK families conducting intensive home-based behavioral intervention
for their young child with autism. Journal of Autism and Developmental
Disorders, 31, 327-336.
Remington, B., Hastings, R.
P., Kovshoff, H., degli Espinosa, F., Jahr, E., Brown, T., Alsford, P., Lemaic,
M., & Ward, N. J. (2007). Early Intensive Behavioral Intervention: Outcomes
for children with Autism and their parents after two years. American Journal
on Mental Retardation, 112, 418-438.
What this graphs shows is that a much larger % of the 309 children in
the behavioural intervention group changed to a reliable extent on IQ and
adaptive behaviour over two years compared to the 144 children in the
control/comparison intervention group. This is, as far as I am aware, the
largest controlled comparison of outcomes from behavioural intervention for
young children with autism ever reported.