Revisiting ABA: Addressing Historical Concerns, Ethical Evolution, and Client-Centered Care for Autism.

       It is not staggering that some people living with or without autism and developmental disability may be skeptics of the effectiveness of applied behavior analysis (ABA). This stems from the history of ABA using aversive interventions like electric shock etc. In other words, these aversive interventions have been haunting ABA in recent times even though now there is a board; Behavior Analyst Certification Board (BACB). The BACB has developed an ethical code to protect clients and practitioners. It is important to note that ABA is not the only field that has faced anti sentiments, medicine has also had its own share of anti-sentiments. There has been talks about autism being linked to the MMR (Measles, Mumps and Rubella) vaccine. An article by Gerber and Offit (2009) highlighted eight children exhibiting signs of autism a month after getting vaccinated with the MMR vaccine (p.456). Imagine a parent or caregiver reading such an article, it is likely he or she may have doubts about the positive effects of this type of vaccine. This article is just one of the different articles available about the MMR vaccine possibly causing autism. However, this reflection will be on the experiences of people with autism with applied behavior analysis, the question of if ABA is socially valid, proclaiming neurodiversity in applied behavior analysis, rationality, disability medical model and humanism in ABA and Autism Spectrum Disorder (ASD), ten rules for conversing about behavior analysis and interpreting the covenant of behavior analysts as an envoy and interpreter.

      According to Anderson (2023) ABA was developed to treat behaviors of people living with autism (p.738). This is evident in the definition of applied behavior analysis which aims to improve socially significant behavior such as communication skills, social skills and daily life skills. This can be challenging for people with autism and developmental disabilities. One may argue that who determines what is acceptable behavior. Notwithstanding, as humans anything that can produce harm or prevent someone from living a comfortable life is grounds for improvement. The article also argued that the people living with autism do not want to be treated identical to their peers that is people that society perceive as “normal” (p.738). This is understandable as most humans wants to be accepted for who they are. They do not want to be seen as helpless and dumb or unclever as they also have a voice. However, even though some may be non-verbal and as such may not be able to communicate in the way that is socially acceptable, they also have emotions, and it should be taken into consideration. Another crucial point raised was the fact that people with autism do not want interventions to change their behavior and who they are, yet they want the interventions to help them control their behavior (p.738). I am at crossroads with this statement because I thought behavior interventions aimed at self-harm helps people with autism and development disability to control that behavior so that they do not end up harmed. Additionally, people that do not have autism or developmental disability sometimes need to unlearn certain behaviours, so this is not justified. Unlearning a behaviour does not mean you are changing who you are. For example, I use to bite my nails as a teenager even when I was not nervous. I stopped as soon as I started dental school and learnt about infection control. I was aware sometimes I was not constantly washing my hands hence transferring germs to my mouth. Did it change who I was as a person? I would say no, and this was a behaviour I had to unlearn. Also, the article raised concerns of clinicians of ABA not seeking consent from the people with autism before carrying out interventions (p.738). I am aware the ethical code 2.11 obtaining informed consent requires all behaviour analysts and student behaviour analysts to follow this code. I am just wondering if those that did not seek consent were unaware of this code or were not behaviour analysts and as such not obliged by this code. Also, behaviour analysts are also obligated to seek assent before proceeding with any intervention, so I am astonished this was even a concern.

           Cumming et al. (2023) elaborated on the use of the Lovaas method back in the 1970s which provided the illusion that autism could be cured, and children would not need to be institutionalized (p.73). This was also highlighted in the article by Anderson (2023) (p.738). This is relatable because as parents and caregivers, we may want our children with us all the time to bond and protect them so any intervention that would keep them home is going to be convincing. Looking back to the 1970s, people with autism and learning disabilities were not easily accepted to live with the general population. However, things have changed in recent times and ABA aims at improving behavior and not curing autism. The article also spoke about Positive Behavior support (PBS) and it being an extension of ABA (p.73). Moreover, it is surprising that people still link PBS to ABA when PBS is not data driven. Similarly, the article argues that if a person receiving an intervention does not trust procedures or goals even if the intervention is productive, it does not mean it is relevant (p.74). This is where assent is a necessity. If a client does not trust an intervention provided, they may potentially be non-compliant and that is not helpful in the long run. In order words, trust and compliance is built when clients are actively involved in their own care.

          Consequently, Mathur, Renz and Tarbox (2024) highlighted the need for ABA providers to pay attention to the concerns of the people they serve (p.471). This is vital because ABA providers should always be looking for ways to improve services through constant research. Additionally, ABA is always evolving so there is a need for providers to be up to date on knowledge through CEUs. The article reiterated that nonautistic individuals cannot understand the physical, emotional and sensory experiences of people with autism (p.471). In my opinion until you walk in someone’s shoes, you cannot question if the persons feet are hurting. In my view, even in everyday life, people deal with situations differently even identical twins that are genetically identical. Basically, no one can compare how they feel without being in the situation themselves. This is why ABA is individualized because interventions work differently on different people. Similarly, the article raised the point of people with autism preferring to be called autistic instead of the former (p.472). Under the core principles of the ethical code; treating others with compassion, dignity and respect, behavior analysts and student behavior analysts must respect how their clients want to be addressed. It is important to note that the article elaborated on the discrimination this vulnerable population face especially in the workforce (p.472). I agree that certain jobs do not require eye contact example being a remote phone customer care representative. Hence why should the person with autism be rejected after a job interview because they were no eye contact during the face-face interview process.

           Shyman (2016) highlighted the fact that the medical model sees autism spectrum disorder (ASD) as a pathology and needing to be cured or treated instead of accepting the individuals with autism (p.367). This ideology was also seen in the article by Anderson (2023). While I agree they should not be treated as diseased, its correct to say they are different from societal perspective. Autism and developmental disability sometimes come with other issues. An example is if a person with autism has some mental health issues in addition to autism, there may be a need for psychotropic drugs to be given and this is done to protect them. Also, the article raised concerns on the amount of power given to individuals in the medical model and who determines what is normal or abnormal (p.369). I agree that an individual receiving care should have the option to decide what is good for them. However, sometimes in the case of those with severe autism or developmental disability, they may not be able to decide, and the decision falls on caregivers and parents to make good decisions. This does not mean the power of these individuals have been taken away. Sometimes, some of these individuals may be nonverbal and unable to communicate. Furthermore, even though assent may be sought, they may not fully understand the risks and benefits of whatever intervention to be provided. This is part of the reason for other stakeholders make decisions on their behalf.

         Critchfield (2014) discussed the need for behavior change to be step by step (p.141). The same way applies to individuals that do not have autism as behavior change is not done overnight. In other words, it should not be expected for people with autism and developmental disabilities to also change their behavior overnight. An example is I was in dental school for 6 years, but I only mastered restorative procedures after practicing for 2 years. Even with that I cannot declare myself as perfect and there is always room for improvement. It also goes for ABA interventions that involves clients, parents and caregivers. These people are not experts in the field, so it takes time and commitment for them to grasp certain concepts, so behavior analysts need to be patient. Additionally, the article reiterated the need for connecting behavior with natural reinforcers. For example, when there is cold air blowing, we grab clothes to cover up with clothes, so we feel warm. What precedes the response of getting clothes to cover up is the cold air blowing. We respond by grabbing clothes to cover up and the consequence is feeling warm. Due to the fact we are aware covering up with clothes will make us warm, in the future, we are more likely to grab clothes when we feel cold to keep us warm, and this is what reinforcement is about. In this case, there is operant conditioning. Another notable point raised by the author was about picking battles when it comes to behavior analysis as a lot of people has certain misconceptions about behavior analysis (p.141). This may stem from the history of behavior analysis. Moreover, imagine a parent or caregiver who has heard testimonials and seen a family member use a pseudoscientific intervention, and it has ‘worked’. Trying to convince such a person to change their mindset on it may be nearly impossible. The behavior analyst may have to sit down such parents or caregivers, explain with data the repercussions of that pseudoscience before they may change their mind. Even that may not be convincing for some people and there is no need to argue with people on their beliefs.

        Foxx (1996) article supports the point I raised in the introduction about the aversive interventions used in the history of ABA. The article elaborated on how some behavior analysis interventions have caused harm and disturbed the image of behavior analysis (p.148). One may say these aversive events occurred in the past and there is an ethical code and a board (BACB)now to prevent such occurrences however, some clients have been traumatized already. This makes it hard for them to accept ABA. This article also discussed the fact that families just want to understand their children and that’s why they approach ABA for help in that area (p.150). Behavior analysts should not forget all these debates about what good or bad interventions affect our clients and their families. In other words, it can be confusing especially for a parent or caregiver who thinks they are doing their best for their child. This is why behaviour analysts need to explain all interventions and procedures in very simple non-technical terms.

      One thing that was resonating in all six articles was the fact that people with autism and developmental disability want to be treated as humans and should not be discriminated. This can easily be corrected by ABA providers as they need to ensure clients are active participants of their care. It was also good to know that the article Anderson (2023) was written by an author who also has autism. I believe the best way to get lived experience is from someone who has autism. The article by Mathur, Renz and Tarbox (2024) was written by authors with developmental disability not autism. Also knowing how tedious writing a paper can be, it is quite refreshing to have someone with autism or developmental disability writing articles. Additionally, it proves some people living with autism or developmental disability can be highly intelligent individuals and should not be underestimated.

         In conclusion, it is good a lot of procedures and interventions have changed in ABA over time, but it is important for behavior analysts to change people’s negative perceptions of ABA. Also, behavior analysts must ensure clients and stakeholders are adequately educated on positive aspects of ABA and consider their client’s voice in determining interventions.

References 

Gerber, J. S., & Offit, P. A. (2009). Vaccines and autism: a tale of shifting hypotheses. Clinical Infectious Diseases: an Official Publication of the Infectious Diseases Society of America, 48(4), 456-461.

Anderson, L.K. (2023). Autistic experiences of applied behavior analysis. Autism,
27(3), 737-750.

Critchfield, T.S. (2014). Ten rules for discussing behavior analysis. Behavior Analysis
in Practice, 7, 141-142.
Cumming, T.M., Strnadova, I., Danker, J., & Basckin, C. (2020). “I was taught that my
being was inherently wrong”: Is applied behavioural analysis a socially valid practice?
International Journal of Arts Humanities and Social Sciences Studies, 5(12), 72-82.

Foxx, R.M. (1996). Translating the covenant: The behavior analyst as ambassador and
translator. The Behavior Analyst, 19, 147-161

Mathur, S.K., Renz,E., & Tarbox,J. (2024). Affirming neurodiversity within Applied
Behavior Analysis. Behavior Analysis in Practice, 17, 471-485.
https://doi.org/10.1007/s40617-024-00907-3

Shyman, E. (2016). The reinforcement of ableism: Normality, the medical model of
disability, and humanism in applied behavior analysis and ASD. Intellectual and
Developmental Disabilities, 54(5), 366-376.