Note: This opinion piece is shared by A. Pablo Juárez, M.Ed., BCBA, LBA, co-director of the Vanderbilt Kennedy Center Treatment and Research Institute for Autism Spectrum Disorders (VKC TRIAD). This commentary is not meant to be a definitive resource documenting numerous issues surrounding the use of applied behavior analysis, but to instead provide a surface-level overview of conversations currently being held among self-advocates and disability support professionals.
In my final Behavior Analysis class as an undergraduate trainee, my classmates and I were told that we were on our way to becoming behavior analysts and having the answers to solve all the world’s problems. My first job out of college was with a hospital-based neurobehavioral rehabilitation program for adolescents and adults with brain injury. I was able to have important conversations with these newly disabled people and their families about goals, needs, and desires. It was hard and heavy work for a young twenty-something, work I would have completely failed at had it not been for the lessons I learned on the job – not only from the patients and their loved ones, but also from my colleagues: physicians, nurses, neuropsychologists, direct service providers, speech-language pathologists, occupational therapists, physical therapists, vocational rehabilitation experts, social workers, and case managers.
It was a fast track to understanding how little I truly understood, and I’m grateful for it. I learned my education and training as a behavior analyst lacked important context and nuance; it lacked key perspectives. Since then, professionals within the field of applied behavior analysis (ABA) have started to realize that these gaps exist, but in the meantime, the awareness of these deficits has grown into a strengthening opposition to the practice of ABA. In this commentary, I hope to share some of my current understanding of this opposition and some ways forward to substantively improving ABA training and services.
What is ABA?
Applied behavior analysis has become a commonly practiced service for people with disabilities, particularly autistic children*. In ABA, practitioners use procedures based on principles of behavior (such as reinforcement) derived from over a century of research. As a science of learning, the uses of these procedures are most successful long-term when the focus is placed on teaching what to do as opposed to teaching what not to do. At its best, ABA is focused on skill development to support the needs of the person being served so access to happiness and safety is accessible and expected. At its best, ABA is tailored to the person’s needs and interests by means of providing them with autonomy and self-determination throughout their experience with ABA and beyond. While there are some truly excellent behavior analysts providing exceptional service, the unfortunate truth is, the best of ABA isn’t always reality for the people we serve.
An important note for behavior analysts as this commentary moves forward: We’re all familiar with the seminal 1968 paper on the seven dimensions of ABA by Baer, Wolf, and Risley.[efn_note]Baer, D. M., Wolf, M. M., & Risley, T. R. (1968). Some current dimensions of applied behavior analysis. Journal of Applied Behavior Analysis, 1(1), 91–97. https://doi.org/10.1901/jaba.1968.1-91[/efn_note] While it’s a vital cornerstone to our science and practice, I’m always surprised when I meet behavior analysts who are unaware of their revisit of these dimensions in 1987. In this paper, they make the following point: “Initially, the meaning of applied centered on vague concepts of social problems, social interest, and the immediate importance of the behavior or its functional stimuli to the behavior. Twenty years of experience, especially with what is often called social criticism, have begun to clarify what social problems, interests, and importance are.” They go on to discuss the importance of social validity to effectiveness of ABA. These points only become more salient as we learn more as a field and as a society.
Why is there opposition to ABA?
There are many reasons people feel compelled to oppose the practice of ABA, and it is important to acknowledge that there is validity to some concerns. In fact, the description of ABA in the previous section does not largely match the understanding or experiences of people who oppose ABA. Further, as a person who has reviewed innumerable behavior analytic plans over the past two decades, I readily agree that ABA practitioners can and do miss the mark. While there are several reasons people may oppose ABA, two of the biggest categories of concern I’ll focus on are compliance and conformity. Each are broad categories comprised of several subcategories of concern, but here are a few key points.
In discussion related to ABA opposition, compliance is often used as a term to describe the exertion of authority and/or power over a person in a way that compels that person to follow directions or rules. Advocates point to the very real issues an overreliance on compliance training could bring, particularly in terms of safety. If a person doesn’t learn to self-advocate along with learning to follow directions, there can be very real risks to physical and emotional safety, especially in services where assent isn’t readily gained for the person being served.
Conformity, in some ways, is also a form of compliance – to social rules and conventions. Historically, there has been a predominant focus by professionals (behavior analysts, speech-language pathologists, occupational therapists, physicians, educators, etc.) in teaching skills to the people we are serving which match those deemed most socially “acceptable.” In terms of ABA, this certainly rings true through the history of the field. It takes very little searching to find examples in the scientific literature of behavior analysts teaching eye contact or working to decrease non-harmful self-stimulatory behavior.
Goals focused on compliance and conformity are examples of ableist goals advocates rightly say do not honor neurodiversity.
These, among others, are examples of goals advocates rightly say do not honor neurodiversity and could be labeled as ableist (disability-centered discrimination based on traditional social expectations). This is especially true for goals rooted in a medical model versus a social model of disability which should also account for intersectional issues with acceptance and support in accessing an inherently ableist society. There’s an excellent primer on these issues for behavior analysts in Schuck, et al. (2021),[efn_note]Schuck, R.K., Tagavi, D.M., Baiden, K.M.P. et al. Neurodiversity and Autism Intervention: Reconciling Perspectives Through a Naturalistic Developmental Behavioral Intervention Framework. J Autism Dev Disorders (2021). https://doi.org/10.1007/s10803-021-05316-x[/efn_note] which is written by a number of autistic researchers and providers and discusses a framework for supporting and honoring neurodiversity within naturalistic developmental behavioral intervention.
Compliance and conformity can be well-addressed by behavior analysts rethinking goal development (a little more on this to come). However, goals are based on information learned from assessment and analysis of behavior. Some of these analyses and subsequent interventions are often cited as problematic by those who oppose ABA. For example, there are test situations behavior analysts may conduct which are designed to evoke the behavior to be addressed. As such, a behavior analysts may run a series of tests in which they want to see which situations result in the person engaging in aggression or self-injury. They can then construct interventions to address those very behaviors. While I believe these types of analyses are sometimes needed, significant issues arise when they are not used judiciously, much less appropriately and correctly.
With regard to interventions, there is a long history of troubling ABA interventions (e.g., repetitive drills, removal of preferred items only to have the person earn access to those items by engaging in the “appropriate” behaviors, planned ignoring) that are often unnecessary and prove to be ineffective in the long-term. High-quality ABA services focus largely on skill acquisition. In other words, we teach what to do, but is what we are teaching socially acceptable? Not always.
What should behavior analysts do?
Behavior analysts could correctly suggest that the kind of compliance previously described doesn’t meet the technical definition of compliance. Behavior analysts could (and often do) suggest the goals of ABA are not to conform but to open the person to more opportunities for social reinforcement and growth within society. Those behavior analysts who jump to these arguments or attempt to correct what they view as ABA misinformation are often missing the point entirely. They are making the discourse on ABA even more polarizing and challenging. If we can’t listen, how can we expect others to? What behavior analysts should be hearing is, ABA goals and procedures aren’t always as socially acceptable as we think they are, and as Baer, Wolf, and Risely (1987)[efn_note]Baer, D. M., Wolf, M. M., & Risley, T. R. (1987). Some still-current dimensions of applied behavior analysis. Journal of Applied Behavior Analysis, 20(4), 313–327. https://doi.org/10.1901/jaba.1987.20-313[/efn_note] tell us, “If an intervention is socially invalid, it can hardly be effective, even if it changes its target behaviors thoroughly and with an otherwise excellent cost-benefit ratio; social validity is not sufficient for effectiveness but is necessary to effectiveness.”
Ableism is a significant barrier to the progression of ABA as a practice which should be based in science and humanism. For example, while there’s not space here to take a deep dive, one of the many things behavior analysts need to stop doing is writing compliance goals. Instead, we should focus on teaching skills such as engagement and safety, along with self-advocacy. Almost every instance of a compliance goal can likely be reframed into an engagement or safety goal. All people need to follow directions and rules; no one is arguing against that. However, compliance training as means to teach a person simply to comply is wrong and often primes others to consider compliance as a given non-contextual necessity. It is not, and this concept can be and has been dangerous.
Most behavior analysts would likely argue that this isn’t how they view compliance at all. That’s not what the community is telling us they see, though, and quite frankly, they’re not wrong. The field of ABA needs to do a much better job of listening and learning. Behavior analysts know learning is a change in behavior through experience, so we can only say we’re learning when we actively attempt and demonstrate socially valid change. Behavior analysts (and other providers) need to demonstrate substantive, community-informed change in the ways behavior analysts are trained and assessed for providing ABA services at local, state, and national levels.
Behavior analysts (and other providers) need to demonstrate substantive, community-informed change in the ways behavior analysts are trained and assessed in providing ABA services at local, state, and national levels.
For behavior analysts looking for a concise read on ethical decision making, including the need to focus on client values and contextual needs, I strongly recommend Contreras, Hoffmann, and Slocum (2021).[efn_note]Contreras, B.P., Hoffmann, A.N. & Slocum, T.A. Ethical Behavior Analysis: Evidence-Based Practice as a Framework for Ethical Decision Making. Behav Analysis Practice (2021). https://doi.org/10.1007/s40617-021-00658-5[/efn_note]
Is substantive change possible?
Yes. However, there are many barriers the field of ABA needs to grapple with in collaboration with community members and partners. Community engagement at high levels of the field has been inconsistent or poor. Dogma and conflicts of interests within research and practice are common. The way insurance funds ABA contributes to a limitation of contextual variability and person-centered service delivery within ABA clinics, and the growth of large investment-funded corporations running high-volume clinics perpetuates a cycle of socially invalid service. A driver of these issues is the exponential growth in the numbers of behavior analysts via a proliferation of online certification programs. While some of these programs provide quality information and some opportunities for these discussions, the reality is they have little to no incentive to do so, much less to do so well. Additionally, quality practicum and internship training supervision for behavior analysis certification candidates are not always available, whether trainees attend programs online or in-person. Despite all of this, I do believe change is possible, but it is going to take a lot of work at all levels.
How is VKC TRIAD responding?
Locally, TRIAD, Vanderbilt Kennedy Center’s (VKC) autism institute, has been engaging in listening, self-reflection, and change for the past several years in our ABA practices and training. With humility, we set out to listen to community concerns from numerous sources, develop guiding questions and principles to support the change we knew we needed to make, and develop a growth mindset to help ensure we’ll continually be listening, learning, and applying change as needed. We discussed these guiding practice questions and principles with VKC’s Community Advisory Council and other community partners, then adjusted based on feedback. The result is an approach to ABA service delivery which we continue to adjust as we learn more and regularly discuss within team meetings and peer review. We call this community-informed practice (CIP). However, we’re working toward community-assessed practice (CAP), which would necessitate regular review of goals and interventions by a community advisory committee. I am eager for this to become reality for TRIAD by the end of 2022 and am grateful to have a new committee of autistic advisors to support our overall decision making.
In Tennessee, TRIAD has worked with colleagues across the three grand regions to begin discussion on promoting change at the statewide level. As a result, the Tennessee Association for Behavior Analysis is considering a change in focus of their Public Policy Committee to include practice (Public Policy and Practice Committee) with the development of a sustaining external community advisory committee. This committee would include autistic and disabled people, caregivers, other professionals, lawmakers, and more. Pilot initiatives to support private ABA providers in understanding how to improve social acceptability of service delivery while maintaining viability will be important early on. We strongly support these developments and are eager to support socially acceptable and replicable initiatives.
Nationally, TRIAD is working with colleagues from across the country – Alaska, Wyoming, South Dakota, New York, Maryland, Nebraska, Michigan, California, Indiana, Iowa, Texas, Puerto Rico, and more – to develop a large-scale approach to community engagement in resource development for ABA training programs. While this is still in early development, it has been uplifting and encouraging to find colleagues at all professional stages committing to listen to and learn from autistic and disabled people, caregivers, other professionals, etc., at local, state, and national levels. Importantly, we are working with the Association of University Centers on Disabilities (AUCD), which will guide these processes in collaboration with community members and organizations. AUCD is a well-respected national association focused on disabilities and professional training that strives to ensure providers and communities know how to provide best-practice service.
Communities are key.
Local, statewide, and national approaches that are informed and assessed by the communities we serve and work alongside are vital. I never ended up with the answers to solve all the world’s problems, but I did learn that we can solve a lot of them by working together. Behavior analysts have to accept the reality that ABA has significant issues and threats that need to be addressed. The good news is, we don’t need to (and shouldn’t) address them on our own. The very people and communities we’re serving can (and will) help us find those answers, but we need to actively listen and engage.
*TRIAD has adopted the use of identity-first language. For more, see vkc.vumc.org/vkc/triad/identity-language.
Top photo by Getty Images