It is no secret that the ABA field has a troubled past. While the science of behavior analysis is sound, the application of behavioral principles can vary so significantly. As such, we have a great chance of causing harm. This conflicts with our ethical duty to avoid harm to our clients who are often in a vulnerable population.
ABA therapy has changed dramatically over the years. Many common practices that were regularly used a decade ago, are used minimally today, for good reason. However, despite the field's continuous growth, there are unfortunately many practitioners who continue practicing "old-school ways". As such, there are many red flags to look out for when choosing an ABA provider for your loved one, or when choosing a provider to work for.
1. A focus on reducing self-stimulatory behavior
Stimming (short for self-stimulatory behavior) is a type of behavior commonly associated with autism. However, everyone stims. Actions we do that feel good like hair twirling, biting our nails, and rocking in our chairs are all common self-stimulatory behaviors.
Because stimming is a symptom of autism, many in the field have considered it necessary to implement interventions when a learner engages in stimming such as arm flapping and spinning. Reducing stimming was a common practice up until recent years. However, we have come to understand how ableist this perspective and practice is. If we are not expecting everyone to eliminate all stimming, why are we expecting autistic children to? Because stimming is a part of the symptomatology of autism? Because we want to help them to "fit in"?
If stimming is causing harm to the child or others, an intervention is likely needed. Or if the child indicates a desire to reduce this behavior, then it is totally acceptable to target. However, if it is entirely harmless, does not interfere with quality of life, and the learner does not request support in reducing the behavior, then it is likely unnecessary to target. A provider who has a heavy focus on reducing self-stimulatory behaviors for all learners should be avoided. 🚩
2. Focus on sustained eye contact
Some providers believe that eye contact needs to be taught in order for clients to be successful in life. While teaching a child to orient their body or direct their eyes toward a stimulus, can be beneficial for many life skills, sustained eye contact is not necessary.
Think about conversations you have on a daily basis. How long do you maintain eye contact with the other person? Most people at least glance away every now and then. However, I have seen some providers program for direct eye contact for 30-60 seconds. Not only is this unnecessary for communication, but many autistic adults have also spoken out about how physically painful sustained eye contact is. A 2017 article covered one study on this topic, identifying the various reasons why autistic individuals struggle with eye contact.
When a provider has a narrow view on eye contact, blindly (pun intended) targeting direct and sustained eye contact for all learners, you may want to consider steering clear! 🚩 There are many ways to target attending without forced eye contact.
3. Aiming to "recover" or cure autistic people
The idea of "recovering" an autistic person is new to me. I read about it in a few social media posts recently and was appalled, to be frank. An autistic individual doesn't need saving from their disorder. Many autistic individuals consider their autism to be a significant part of who they are. Of course, the spectrum is wide. Many people are in need of a significant level of care, requiring more support than others. Regardless, the goal of therapy should never be to recover or cure the child. If you hear those words, run. 🚩
4. Forced Compliance
This is a very common practice that is only slowly starting to fade away (Painfully slowly). There has been a long-held belief that our clients must follow every instruction we provide. If not, they will think that they can get away with anything. We must show them who the boss is. A black-and-white view on compliance is dangerous in many ways. Our clients are often of a vulnerable population and as such, are susceptible to abuse. Teaching them to blindly follow all commands from an adult or person of authority is a dangerous, slippery slope.
I, again, go back to whether we force 100%, immediate compliance with neurotypical children. I would argue that we do not. It is not uncommon for a parent or caregiver to give their child a few reminders before they actually follow through on an instruction. Furthermore, we often allow neurotypical children to request for modifications when given a demand ("Can I have 5 more minutes to finish this show?"). So why are we requiring autistic children to drop everything the exact second we provide a demand?
ABA providers should be trained in assent and acknowledge assent-withdrawal. Forced follow through should only be used when a client is engaging in highly dangerous behavior which may cause harm to themselves or others. For example, they're running toward traffic and you tell him to stop. To keep them safe, it would be necessary to physically intervene. If you're considering a provider for your child or for a new place of employment, consider asking them whether they follow assent-based practices. If they do not or are unfamiliar with the term altogether, that is likely a sign to look elsewhere. 🚩
5. High recommended hours for all clients
When a provider recommends a high number of hours (i.e. 30-40/week) for all learners, regardless of need, that is a major red flag. 🚩 If your child is recommended for a high number of hours, without the provider being able to justify that need, it is possible that they are motivated to bring in clients with a high number of hours, rather than focusing on individual needs. The number of hours recommended should always be based on individual need.
6. Using food as a reinforcer
This is a hotly debated topic. I won't go as far as to say it's a blatant red flag because it is such a widely used practice. I expect it will take quite some time for us as a field to move away from edibles altogether. Perhaps we'll refer to this one as a yellow flag.
Food is a primary reinforcer. That is, it is something that is innately valuable to humans. Other primary reinforcers include water, warmth/regulated temperature, and sex. It can be damaging to use food as a reinforcer, as food should be provided non-contingently. This may cause children to learn to rely on food to deal with their emotions. In a society where childhood obesity is a health concern, there are also issues with it potentially leading to obesity.
Since I have referred to this as more of a "yellow flag", I would recommend asking a potential ABA provider/employer what their policies are regarding using food as reinforcers. Ideally, they would at least use them as a last resort and never a first.
7. Refusal to collaborate with other providers
ABA is not a one-size fits all therapeutic approach. Many children thrive in other therapies like speech and OT, either on their own or in combination with ABA. A narrow view of ABA as the one and only therapy for autistic children is concerning. It is important for us to consider other perspectives and collaborate with other providers for the benefit of our clients. If a provider refuses to do so, that is not only a red flag, but also an ethical violation.
Takeaways
My main takeaway for you is to thoroughly research a provider, their practices, and values, and see how they align with yours. Prior to initiating services or employment with a new provider, see if any of these main red flags are present. Don't be afraid to ask more questions to get a better understanding before moving forward.
I also want to emphasize that we are all learning and growing. My intentions in this article are not to shame individual providers who are likely doing what they have been taught and surely mean no harm. However, we have a responsibility to our clients to continuously evolve and not simply intend no harm, but actually do no harm. This means shifting our perspectives and long-held beliefs and changing the way we practice.
Resources
Aston University. (2016, April 12). Rewarding children with food could lead to emotional eating. ScienceDaily. Retrieved August 23, 2022 from www.sciencedaily.com/releases/2016/04/160412090707.htm
Trevisan DA, Roberts N, Lin C, Birmingham E. How do adults and teens with self-declared Autism Spectrum Disorder experience eye contact? A qualitative analysis of first-hand accounts. PLoS One. 2017 Nov 28;12(11):e0188446. doi: 10.1371/journal.pone.0188446. PMID: 29182643; PMCID: PMC5705114.
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