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  • Writer's pictureDr. Lisa Marnell, OTD, MBA

ABA in Autism: Short-Term Changes and Long-Term Trauma

Updated: Sep 22

As an autistic occupational therapist who has worked extensively in schools, I have often seen behaviorist approaches used in classrooms. Anecdotally, I have noted that tactics used often make tenuous situations worse. Use of ABA, at home, in centers, and in classrooms, is a huge controversy. If you are curious about this, I have tried to thoughtfully explain it below.

Research shows that ABA results in behavioral improvements, but only in the short term without long-term benefits or generalization of a child’s skills and competence. In fact, in the last two years, research is suggesting some long-term trauma associated with ABA as well as mental health issues.

Much of the concern with ABA is that BCBAs (the people who supervise ABA) are “behavior analysts” who only look at a child’s very surface behaviors but not the bigger picture in the kids’ environments, nor do they dig deeper to understand the underlying neurological reasons for a behavior. BCBAs are NOT trained in neurology, sensory processing, communication, executive function, language acquisition, or child development, yet OTs and Speech therapists do receive this advanced training.

It may help to step back and look at the overarching process through which ABA proceeds.

At the start of ABA, behavior analysts (BCBAs) set behavior goals for a child. Next, they identify what is most motivating to a child and then withhold it (not initially but once a rapport is established) as a reward in future sessions. These favorite things may include toys, play activities, or even affection, and this strategy is formally called a “Motivation Assessment”. This approach is standard and is taught to all BCBA analysts, whether or not the ABA is called new school or old school.

The child’s “targeted” behaviors are then identified and categorized as 1- sensory stimulation, 2- attention-seeking, 3- escape/avoidance, or 4- attempts to access tangibles. The problem lies in the fact that these categorizations are far too simple and in fact, they are not accurate. The deeper reasons for an autistic child’s “behaviors” have been shown to be more complex, such as sensory processing challenges, executive dysfunction symptoms , motor planning difficulties, communication impairments, or simply that a child is not developmentally ready to perform a given task or activity. This all has to do with current research in neuroscience that shows that autistic brains are both structurally and functionally different from neurotypical brains. You cannot change neurology with behavioral interventions.

Parents often see their children “enjoying” ABA or that their kids are eager to go. But parents should perhaps wonder if liking an RBT (many RBTs are smiling, energetic young people) justifies that the expectation of making behavioral demands on a young child for hours and hours a day, month after month. Also, grooming tactics have been noted with ABA, in which an adult gains a child's trust in order to convince them to comply with their wishes or goals which may feel aversive to children.

The even more severe criticism of ABA is that it directly rewards compliance to an adult’s demands, even if these demands are uncomfortable to a child, as would be the case in teaching a child with auditory sensitivity to tolerate the sound of a loud toilet flush or expecting a school-aged child to cope with “small talk” even though the vast majority of autistic adults find neurotypical social expectations and tendencies, like small talk, to be stressful.

Sexual abuse is four times more likely to be suffered by autistic people than non-autistic people, so teaching compliance to an adult’s directive is a moral question that should be thoughtfully considered by parents. Also, complying the best they can when something is challenging for them (from a neurological and sensory perspective) builds stress in autistic children. Plain and simple. Anxiety is diagnosed in approximately 50% of autistic adolescents as opposed to 10 to 15% of the neurotypical population. And I hate to share worrisome statistics, but autistic adults are four times more likely to die by suicide than neurotypical adults.

In fact long-term studies show that ABA does NOT lead to generalization of skills, and it DOES increase the chance of the child developing an anxiety disorder or trauma by adolescence.

Many parents share that their children are doing “well“ in ABA. Immediate rewards do in fact motivate kids to try a skill or to mimic saying a word, but this approach does not address and build the underlying skills, autonomy, executive function, and independence that a child needs to thrive long term. In fact, children who have been in ABA for extended amount of time tend to become prompt dependent and passive, as they have been trained to do what the “therapist” asks them to do in order to receive a reward.

I do realize this is a difficult subject for parents as everyone wants to do what’s best for their child. However here is a very recent study completed by the United States Department of Defense. It shows that long-term use of ABA resulted in either no improvements in skills and/or behaviors or a reduction in skills acquisition in children. ABA sadly, is a multi-billion dollar industry in the United States and there are huge lobbyists within the insurance industry advocating for a standard of 20 to 40 hours weekly for young children.

Why do doctors recommend it? ABA has a long history of being the go-to intervention for autism. But in fact, doctors receive little to no training in autism during their education. Doctors I have spoken to were shocked at the consequences and concerns about ABA that I mentioned.

If you do decide to adopt ABA for your child, then at least know the research, investigate this yourself, and understand the concerns I raised so that you are making the most informed and educated decision for your child. Do not take the choice to do ABA lightly. There is far too much anecdotal trauma reported by autistic people and far too much evidence that ABA may have very concerning long-term impact

Here is the link to the US government article:

More from Dr. Lisa Marnell and Kids Master Skills . . .

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I would love to hear about your successes, your struggles, and any questions or comments you have! Let me know if this post was helpful.

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