ABA Therapy: Pros, Cons, and Why I Left the Field

Introduction

Hello! If you are a parent of a child with autism considering ABA therapy, or an individual considering working in the field of ABA therapy, I hope this blog post may be helpful for you. In this article I will weigh some of the pros and cons I've found in my experience working in ABA and in reading the criticisms of ABA therapy by others within the autism community.

Terms for Reference

RBT: Registered Behavior Therapist - works directly with the child or teen to administer ABA treatment plan.

BCBA: Board Certified Behavior Analyst - Supervises the RBT and creates the behavioral plan implemented by the RBT.

Background

I received my RBT certification at the start of 2021 and started working in ABA therapy on a full-time basis, serving kids with autism ages 3-13. After about 6 months on the job, I discovered some of the opposition to ABA online. The criticisms came both from adults with autism and neurotypical professionals who serve clients with autism. I also found many professionals and parents advocating in favor of ABA. I chose to prioritize what people with autism were saying about ABA over what neurotypical adults were saying because I believe people with autism should be the ones leading the conversation about what type of support is best for kids with autism.

Once I started reading the criticisms and comparing them with my day-to-day work, I chose to leave the field. I came to believe that kids with autism deserve better (higher quality, more empathetic, and more professional) support than what ABA offers, even though I believe ABA is helping many kids with autism achieve some important developmental goals. 

Table of Contents

Part I: Cons of ABA 

Part II: Pros of ABA

Part III: Conclusion

Part IV: Advice for people considering ABA

Part I: Cons of ABA I've become opposed to, or at least conflicted about

1. Many ABA organizations attempt to repress stimming.

If you are unaware, stimming refers to self-stimulating physical behaviors that can be pleasurable or self-soothing. This could include arm flapping, rocking oneself back and forth, repeating sounds or phrases, looking at lights, spinning, etc. These behaviors are not always specific to individuals with autism (think of the average neurotypical individual tapping their foot nervously or anxiously fidgeting with an object in their hand while having an uncomfortable conversation), but they are more common among individuals with autism.

One of the most frequent criticisms I found of ABA was that many ABA organizations attempt to "extinct" stimming behaviors and that this can be very painful and difficult for individuals with autism. A consistent opinion I've found within the autism community is that stimming is generally harmless (with the rare exception of stimming behaviors that may consist of self-harm, such as head banging). 

During my time as an RBT, I worked with two BCBA supervisors who attempted to repress harmless stimming behaviors. Within ABA therapy techniques, BCBAs may ask the RBT to ignore when the child stims or try to block the stimming. I don't believe this is necessary, and in some instances, I think it could be stressful for the child.

A book that really helped change the way I see autism, especially stimming behaviors, is The Reason I Jump: The Inner Voice of a Thirteen-Year-Old Boy with Autism by Naoki Higashida. In his book, Naoki answers very common questions neurotypicals ask of people with autism, such as "Why do you repeat the same thing over and over?" or "Why Do You Never Stay Still?" I highly recommend this book, especially if you are feeling confused about stimming and why your child with autism engages in these behaviors. The tone of this book is very empathetic, and it left me with a feeling of wanting to improve the effort that neurotypical individuals make to understand how it really feels to be autistic.

2. Similarly, many ABA organizations try to force eye contact.

Casey "Remrov" Vormer is a young adult with autism and the author of the best-seller Connecting With the Autism Spectrum. He also expresses his advocacy for individuals with autism on his YouTube channel. In this video, he describes how difficult or painful it can be for some people with autism to process what someone is saying while making eye contact at the same time. It's so important to bear in mind that there is a physiological difference between processing sensory input as someone with autism and as someone neurotypical. Sensory overload can be so much more overwhelming to people with autism because it's a completely different experience. 

For example, visual or auditory input, such as a light turning on or a dog barking in the distance, could be significantly more distracting to someone with autism than someone neurotypical. I recommend allowing individuals with autism to have control over their physical environment. If they seem sensitive to certain sounds their toys make and quickly turn those toys off, or have a habit of turning off certain lights, keep their head down or plug their ears when you lean close to talk to them -- bear in mind they might be feeling overloaded with the sensory input.

3. ABA limits appropriate reactions to all of a child's behaviors into just 4 categories, none of which include comforting a child or offering them a break.

One of the key things you learn during your ABA training is that all behavior fits neatly into 4 categories (attention-seeking, escape-seeking, sensory satisfaction, or access to tangibles) and only gives 4 acceptable correlated reactions to those behaviors: (ignore the attention-seeking behaviors, block the escape and follow through with a demand, redirect the sensory seeking behaviors, and block access to the tangibles). 

My issue with this is that there's no space for reacting with empathy or even attempting to have a conversation with the child explaining the context of why you want a certain behavior from them. None of these 4 reactions involve offering a child comfort or space if a child is feeling stressed. I think most RBTs will have a natural human reaction to offer a child comfort if they're crying or offer them a break if they're feeling overwhelmed. However, these reactions aren't built into the structure of ABA itself, so an RBT without those instincts might never be trained to do so. 

An RBT who takes the ABA techniques very seriously might easily ignore a child who is crying without giving them eye contact or physical comfort. I'll talk more about the ABA technique of "planned ignoring" below in point 8. Another example is that if a child is repeatedly attempting to "escape" an ABA session, ABA therapists are taught to block the door and not allow the child to leave. On one hand, I can see the importance of teaching children that it's not appropriate to run away from undesired tasks, like an RBT telling a child to clean up a mess and the child reacting by running away so they don't have to clean. On the other hand, I believe children will feel less secure in an environment if they feel literally trapped. If a child is repeatedly attempting to escape the room, it could be an attempt to not have to clean up, or it could be the child's way of communicating that ABA is stressing them out and maybe they need a break that no one is offering them.

4. ABA has very little focus on teaching concepts and much more focus on demanding and reacting to the child's response.

ABA is centered around placing demands and then reacting to whether or not the child complies with the demand. There is minimal focus on teaching the child how to achieve the demand you're placing. An RBT's structure consists of first placing a demand, such as asking a child to identify an animal's sound. The child either meets the demand and identifies the animal's sound or does not. If the child does not meet the demand, an RBT may then prompt the child by pointing to the correct answer or by modeling the desired behavior. The RBT continues this process until the demand is met, taking data on the child's behavior throughout the process.

Example: An RBT might say, "What does a cat say? ...No, a cat says meow. Say "meow." 

To me, it would make a lot more sense if there was significantly more focus on teaching the child concepts prior to asking the child the questions. For instance, the RBT could read them a book about animal sounds. ABA can feel a lot like quizzing kids on ideas they "should" know about without providing the context to build up to the questions you ask. I personally ended up bringing in books, making drawings, making up songs, etc., before placing any demands because, to me, it doesn't make any sense to ask a kid to answer a question before making sure they've had a thorough opportunity to learn about it.

The only focus on teaching built into ABA are methods called Naturalistic Teaching and Task Analysis, which I will highlight in Part II, where I share my thoughts on some of the pros of ABA.

5. ABA training is structured almost entirely around understanding ABA techniques and has little to no built-in training on understanding autism itself. 

Things like sensory overload, motor apraxia, or even learning about what autism is and different types of autism within the spectrum are not a part of training to become an ABA therapist. 

This insightful blog post is by Ann Memmott, a professional and international speaker. Ann Memmott is autistic and has been working alongside other adult professionals with autism for over 30 years. Memmott's post really resonated with me, especially when she asked the important question: Does the ABA textbook "even ask what autism is?"

6. Many criticisms I've read online are how ABA can be rigid and repetitive.

One of the reasons I believe this may happen based on my personal experience is because of profit motives where you have ABA companies who push for the maximum amount of therapy hours they can get away with billing to a family's insurance provider. My personal experience with many of the clients I worked with was that their long therapy hours came from a push from the corporate staff, who never once interacted with the children. It felt very transparently profit-motivated on my end when I was struggling to fill the time with the child without the sessions becoming too fatiguing or repetitive for the child. Some kids, as young as 3 years old, are qualified by their insurance provider for up to 40 hours of therapy per week. Imagine a 3-year-old being given response-based demands like "Touch your nose," "What's your name," and "How old are you?" "touch the car" on repeat for 8 hours a day, each time being corrected for wrong answers until they've memorized a compliant reaction.

In addition to session times being very long, the most common method used in ABA is DTT or Discrete Trial Training. This involves first "placing a demand" (asking a child a question or asking the child to perform an action) and then reacting to the child's response. One of my BCBAs was very in favor of a method called "Errorless Learning" that involved over-correcting a child's wrong response, giving the child two demands that are meant to serve as "distractors" and then repeating the question until the child gives the right answer. It looked like this:

"Which one is a triangle?" (Child points to the diamond)

"No. This is the triangle" (Adult points to the triangle)

"Touch your nose." (Child touches their nose) "Touch your head" (Child touches their head)

"Which one is a triangle?" (Child points to the diamond)

"No. This is the triangle" (Adult points to the triangle)

This method is meant to be repeated over and over again until a child gets all questions correct. You can imagine how quickly this could become draining for a 3-year-old child qualified for a 5+ hour session daily.

7. Many argue that ABA attempts to "make autistic kids appear neurotypical"

Earlier, I referenced attempts to control stimming and eye contact, which are the most common examples I've seen in reference to how ABA attempts to make kids with autism appear neurotypical. There is another example I've found that comes up often in ABA. One goal that a BCBA can write into a behavior plan is called "spontaneous imitation in play." 

Here's an example of how it works: You might have a 3-year-old whose play looks different from a neurotypical kid's play. She likes to collect all the plastic food toys, put them inside a box, and then hide the box. A neurotypical kid might be more likely to interact with plastic food like they're a chef cooking. ABA therapists push kids with autism to imitate those types of gestures, such as pretending to say "vroom" with a car or "hello" on a toy phone. They might give the demand "Do this: *says hello into the plastic phone and then hands the child the plastic phone*" repeatedly until the child follows the instruction.

But if play is play and a kid is having fun, why is it necessary to control play? If you were teaching a child functional goals like how to use a real phone or how to prepare real food, I think that teaching them the appropriate way to follow those functional steps is necessary. But is it necessary to control the way a child chooses to interact with play food or play phones for any other reason than "I want my child to play like a normal kid?" To me, this serves no other function than attempting to make autistic kids appear neurotypical. 

8. "Planned ignoring" is a very common technique used in ABA to extinct attention-seeking behaviors, but should it be used as often as it is? 

"Planned ignoring" is a technique that is essentially what it sounds like: in response to a child's behavior that is attention-based, adults ignore the call for attention to show the child that this behavior is not an appropriate way to ask for attention. In some cases, I think this can be very effective. RBTs are often taught to use it to teach a child that hitting or screaming is not an appropriate way to ask for attention. 

The criticism that resonated with me about that was, even if this is effective, does that necessarily mean it's not equally emotionally damaging? Neglect can look like a child learning to self-comfort. The child has given up on attention-seeking behaviors, but that resignation has internal consequences that damage their emotional health and trust in their caregiver.  

In my view, the problem is that if a child is seeking attention by screaming or hitting and they aren't guided towards an appropriate alternative way to communicate their need for attention, then we are blocking an attempt to communicate instead of teaching how to communicate. Many kids with autism are nonverbal or face significant verbal challenges, so they resort to hitting or screaming to communicate their needs. Instead of reacting by ignoring as a means of teaching them that this is not an appropriate way to ask for attention, I think it's crucial to react each time by modeling the appropriate way to ask for attention and then giving the attention after they at least attempt to imitate what you've modeled.

Example: A child is hitting, and a parent suspects that the child is doing it for attention. A parent could ignore to teach the child they won't get attention from hitting. This could effectively stop the child from hitting, but it doesn't teach the child an alternative way to communicate. 

If the parent or RBT acknowledges the hitting by ignoring it and models appropriate behavior, it would look more like this:

"No hitting. Say, Mom I want __(hug, toy, juice etc.)" and when the child imitates what you've modeled and at least attempts to say what you've said "Mom hug", you could give them the attention they're asking for. Kids with autism can often struggle verbally, so saying something like, "Mom, I want__" when there's something they want might not come as naturally as easily as it can for neurotypical children.

9. Organizations Comprised of Adults with Autism are largely anti-ABA

Individuals with autism should be the ones leading the conversation about what types of therapy are best for kids with autism. The opinions of neurotypical professionals are secondary because we won't ever understand the experience of living with autism the way neurodiverse individuals do. 

It was very telling for me when I discovered that the Autism Self Advocacy Network is in support of physical therapy, speech therapy, and occupational therapy but not in favor of ABA. You can find their views here under "Autism Research and Therapies"

Other autism groups who speak out against ABA therapy include:

Ido Kedar is an author with autism who had ABA treatment as a child and talks about his experience, feeling that ABA does not understand the disconnect between mind and body he lives with.

Autistics for Autistics, a Canada-based autism advocacy group states, "It is our view that the ABA industry has been engaged in this type of exploitative marketing in Canada and the US. It is also our view that ABA, which has no evidence of benefit and clear evidence of harm, should be de-funded."

But even outside the opinions of those with autism, many neurotypical professionals have spoken out against ABA. I even discovered that many speech therapists are anti-ABA which I found very interesting because it tied into what I read from the Autism Self Advocacy Network in favor of therapies such as speech therapy while being against behavior therapies like ABA.

I was also personally very influenced by this blog from another previous ABA therapist who left ABA.

Part II: Pros of ABA that I believe are more helpful than harmful

1. Task Analysis

My favorite technique sometimes used in ABA is called "Task Analysis." I feel good about this technique because it empowers kids to accomplish new goals independently at their own pace (rather than demanding a correct answer on the spot).

The way Task Analysis works is very simple, and it's generally applied to the types of goals that kids practice in occupational therapy. It can be used for things helping kids with motor challenges learn how to independently practice hygiene or functional skills such as: 

• Getting dressed
• Brushing teeth
• Taking a shower
• Setting a table
• Tying shoes 

These tasks are broken down into steps and often have a visual chart component to guide the child along. The idea is to prompt the child through the steps one by one until they've memorized each step. The RBT supports the child with step-by-step prompts and gradually withdraws their prompting to help the child master each step on their own. You might be holding your hand over theirs while teaching them how to brush their teeth or counting to ten aloud while they brush one side of their teeth. As they memorize and master each step, you slowly withdraw your prompts.

In my experience, this process has been largely positive for the kids I worked with. I like that it empowers their independence and that it allows them to learn at their own pace without punishing "wrong" reactions. 

These same skills are also very similar to what occupational therapists might offer a child with autism, which is another option to consider if you want a different type of support for your kids with autism outside of ABA.

2. Naturalistic Teaching

This method is exactly what it sounds like. In my opinion, it's very underutilized in ABA. During the time I worked in ABA, my BCBA said that I have a knack for Naturalistic Teaching, which I was proud of. This method involves subtly teaching a child a concept during their natural play. In ABA, you can ask a child a question directly, such as "Point to the triangle" (Discrete Trial Training), or you can find a way to slip it in during play and quietly note their response to see if they know the answer (Naturalistic Teaching). 

For example: "I want to build a roof for our house. Can you hand me a triangle block? Thank you! Now we can put the dolls inside".

I used this method a lot while coloring and singing with kids because creative play allows a lot of room for throwing in all sorts of random concepts. I think kids feel most at ease with this method because you can easily incorporate silliness while they're learning, which helps build their sense of trust in spending time with you.

3. Expanding Vocabulary

A common goal for many children in ABA is to expand their vocabulary since many kids with autism face verbal delays. In ABA, teaching new words is referred to as "tacting." Tacting involves asking, "What is this?" while pointing to a picture of an everyday object. 

As I mentioned in my list of cons of ABA, I definitely think there should be a lot of space for breaks and consideration not to overload a child with too many questions or demands. I think it's really important to be mindful of the child's stress levels and make sure they aren't being overloaded, especially since expanding language can be much more challenging for kids with autism than it is for a neurotypical child. 

If a good therapist is monitoring a kid's mood while helping teach them these new words, I think this aspect of ABA can be extremely helpful for kids with autism in learning how to verbally label things they encounter in their everyday lives. 

I think a great way to teach these skills is by using the Naturalistic Teaching method I mentioned above, like intentionally putting on videos, playing songs, or reading picture books that incorporate some of the words they're struggling to learn. 

Similar to Task Analysis, I believe this is a skill that a speech therapist might be better equipped to support your child with. Especially considering what I mentioned before about how many speech therapists are anti-ABA.

4. Offers Support to Parents who Might Have None

While I might have come to the conclusion that occupational therapy, feeding therapy, speech therapy might, or personal counseling be higher quality support for kids with autism, that doesn't mean all parents can afford those other types of therapies. ABA therapy is one of the most common types of therapy covered by insurance for children with an autism diagnosis. If you're a parent of a child with autism engaging in dangerous behaviors like running in the street, self-harm, or aggression toward others, ABA might be the only option you have in receiving affordable support for these behaviors. 

Many people within the autism community who are anti-ABA are very quick to throw around phrases like "You're abusing your child!" when the topic of ABA comes up because of all the controversy surrounding it. After working with many parents of kids with autism, I really believe these parents are under-supported and deserve any level of support they have access to.

Part III: Conclusion

The qualms I gathered with ABA were enough to push me toward the decision to leave the field. The most significant feeling I have is the concern that ABA isn't doing enough to understand how it feels to experience autism. I would love to hear more from individuals like Naoki Higashida and other advocacy leaders who speak about what types of therapy they believe best serve the needs of kids with autism. In the meantime, I think it's important to listen to the individuals with autism who have already spoken out about how they feel about different types of therapy serving kids with autism.

Part IV: My Recommendations for Parents Considering ABA Therapy for Their Child

Consider what types of goals you are looking for support in. Are you looking for help with a child's verbal skills, functional skills, or improved eating habits? You might be able to find a qualified speech therapist, occupational therapist, or feeding therapist within your health insurance network who offers higher-quality support than ABA therapy would. These other types of therapy all require a Master's degree to go into the field, but ABA only requires a high school degree for RBTs (the ones spending the most time with the child during ABA).

If you go forward with an ABA therapist, I recommend asking your potential therapist the following questions:

1. "What is your philosophy on stimming?"

I'd be wary of therapists who come across as very anti-stimming

2. "How do you feel about eye contact?"

I'd be wary of therapists who come across in favor of forcing eye contact

3 ."Do you tend to use DTT or Naturalistic Teaching methods more frequently?"

I'd recommend asking if the therapist could use more Naturalistic methods than DTT (Discrete Trial Training - this method is more based on rigid drills and less play-based)

4. "What are some of your favorite books/resources about autism?"

Take note if the resources/books they suggest are by individuals living with autism or neurotypical individuals trying to cope with autism

5. "How do you cope with a child dealing with sensory overload?

I would be wary if they seem unfamiliar with how to react to a child feeling sensory overload or if their reaction lacks sensitivity 

I hope this blog post has been helpful for others researching ABA therapy. 

-A neurotypical ally and prior ABA therapist