Hello, and welcome back to The Autistic Writer. Does being autistic require therapy? The idea that autism requires some kind of medical or therapeutic intervention is controversial. This controversy is related to a war of ideas being waged over autism, which, in its simplest form, is a conflict over whether autism is a disorder, or a difference.
The controversy is fed, in part, by the fact that autistic people often struggle with mental health problems. Depression and anxiety are common in autistic people, and sensory overload can trigger autistic meltdowns, which are often interpreted as mental illness. When these issues are conflated with autism, it leads to a popular misconception that autism is an illness that has to be treated or therapised.
This article is intentionally critical of ABA. It’s not an attempt to create an artificial balance between both sides of the debate, but to explain how and why I’ve reached my own conclusions after reading the history, the research, and listening to the experiences of autistic people who have undergone ABA. Where evidence is uncertain or contested, I’ve tried to make that clear, and I’ve distinguished as carefully as I can between established evidence and my own judgement.
My Story
The main reason I eventually discovered that I’m autistic is that I went through a long and difficult period of autistic burnout. During that time, I was diagnosed with depression, and while it’s certainly true that I was depressed, the diagnosis of depression was not addressing the real issue; that I was an autistic person who had no idea he was autistic, and living that life for 50+ years had been mentally debilitating. Eventually, I was fortunate enough to see an occupational health GP who coincidentally had a background in autism. He quickly spotted that I was autistic, and pointed me in the right direction.
Just over 19 months after seeing that GP, I received a formal diagnosis of Autism Spectrum Disorder (formerly Asperger Syndrome). Like many people receiving that diagnosis in adulthood, I didn’t quite know what to do next. I looked around for support, and found, to my shock and bemusement, that support for recently diagnosed autistic adults is hard to find.
As I engaged with my newly found autistic peers online, I learned that most support for autistic people is aimed at children. I was throwing myself into learning everything I could about autism, and so I took a good long look at the support for autistic children. I found a number of things that were very troubling. None more so than the prevalence of a therapy called Applied Behaviour Analysis, or ABA.
“Good intentions may do as much harm as malevolence if they lack understanding.” ~Albert Camus
“Nothing in all the world is more dangerous than sincere ignorance and conscientious stupidity.” ~Dr Martin Luther King Jr.
What is ABA?
ABA, which is normally described as a therapy, consists of interventions designed to change an individual’s behaviour. It uses a system of reward-based encouragement to drive behavioural change. Historically, it has also used negative reinforcement, such as punishment or withholding rewards, to discourage certain behaviours.
ABA is controversial for several reasons. Some of the concerns include:
- The therapy is poorly regulated, with some practitioners having very little training or expertise.
- That it medicalises autism, as something to be treated.
- That it addresses only behaviour, not the overall wellbeing of the autistic person.
- Many autistic people who underwent ABA in childhood have reported symptoms associated with post-traumatic stress disorder (PTSD) and depression that they have attributed to their experience of ABA.
What is the Aim of ABA?
Here are two examples of what proponents of ABA have to say about its aims. Please note that these descriptions of ABA do not constitute an endorsement of ABA by me.
This is a direct quote from the What is Applied Behaviour Analysis (ABA)? section of the childautism.org.uk website:
Applied Behaviour Analysis (ABA) is the practical application of behaviour analysis to address socially significant behaviours. ABA uses behaviour analysis techniques to find unique ways of supporting children in achieving their goals.
ABA is often used in fields like education, therapy, and business. It can help with anything from eating disorders to traffic control.
One of ABA’s most common uses is supporting individuals with autism or developmental disabilities.
Autism Speaks, a controversial autism charity that continues to be the subject of much criticism from the autistic community, has this to say:
Applied Behavior Analysis (ABA) is a therapy based on the science of learning and behavior. [..]. ABA therapy applies our understanding of how behavior works to real situations. The goal is to increase behaviors that are helpful and decrease behaviors that are harmful or affect learning. […]. The methods of behavior analysis have been used and studied for decades. They have helped many kinds of learners gain different skills – from healthier lifestyles to learning a new language. Therapists have used ABA to help children with autism and related developmental disorders since the 1960s.
These descriptions of ABA are typical of how the aims are described. Words like “help” and “improve” suggest that ABA is a supportive practice. You might notice on reading these descriptions that the language is somewhat vague. They do not give specific examples of the methods that are used.
Controversy
The positive descriptions of ABA provided by its practitioners are out of step with the opinions of many autistic adults who report detrimental effects on their mental health resulting from ABA. The controversy is not limited to anecdotal reports from autistic people, however.
The National Autistic Society’s website describes the early forms of ABA as “barbaric.” It softens this description a little regrding moderns types of ABA, but still recommends an alternative called Positive Behaviour Support (PBS), which is described as more person-centred.
However, some autistic advocates argue that PBS functions as ABA under a different name because it continues to define certain behaviours as problems and still seeks to modify behaviour using reinforcement. The behavioural goals of PBS are often chosen by professionals rather than the autistic person, and the perceived success of the therapy is still measured by behavioural outcomes.
In other words, critics of PBS argue that the philosophy has not changed as much as the branding suggests.
A paper by Henny Kupferstein (2018) concluded that there is a correlation between exposure to ABA and symptoms of PTSD in autistic people. This study did receive some criticism regarding inadequate methodology, and it is fair to say that the study does not prove a causal link between ABA and PTSD. However, this does not mean reports from autistic adults should be dismissed.
A 2024 systematic review also criticised the methodology of other studies that have drawn an association between ABA and PTSD-like symptoms in autistic individuals. However, it is important to note that these criticisms do not dismiss the legitimacy of the question of whether ABA causes psychological harm, but the methodology of the studies.
Where Autism is approached from a medicalised standpoint, then within that framework, rigorous methodology is necessary if a causal link between ABA and PTSD is to be established. However, autistic people do not live solely within a medical framework. It would be unwise to dismiss the veracity of the reports of autistic people simply because no research has yet proven a causal link. It might be that it is not possible to find incontrovertible scientific proof of such a link, but that would not prove such a link does not exist: Absence of proof is not proof of absence.
Why Would ABA Cause Trauma?
“ABA is essentially dog training for human beings, designed to crush autonomy and force a marginalised group to mimic the behaviours of the majority, regardless of the psychological cost.” ~Dr Nick Walker, autistic educator.
“The fundamental premise of ABA is that autistic people are wrong, and that our survival depends on hiding who we are. It is the trauma of being told that your natural way of being in the world is a defect that needs to be erased.” ~Julia Bascom, autism rights activist.
So far, we have seen that proponents of ABA position the therapy as help and support for autistic children, but many autistic adults have reported suffering mental trauma as a result of undergoing ABA. We have also seen that the National Autistic Society has described early ABA as “barbaric.” This would seem to be borne out by the quotes from Dr Nick Walker and Julia Bascom, above. But how can an allegedly supportive, helpful therapy be harmful?
A Short History of ABA
During the 1960s and 1970s, behavioural psychologist Ole Ivar Lovaas began applying the principles of behaviour analysis to autistic children at the University of California, Los Angeles (UCLA). Lovaas is a hugely controversial figure, and I will provide a detailed profile of him and his work in a future article.
Lovaas developed what became known as Early Intensive Behavioural Intervention (EIBI), which he developed following on from earlier work in behaviourism, from the likes of BF Skinner. At the heart of Lovaas’s approach was Discrete Trial Training (DTT), a method in which complex skills were broken down into small, teachable steps. Children were repeatedly presented with prompts, rewarded for correct responses, and corrected for errors, with the aim of gradually shaping more complex behaviours.
Lovaas directed his evolving techniques, which would become ABA, toward changing the behaviour of autistic children. In the 1960s, autism was seen as a psychological problem that required treatment to correct. Lovaas’s position was that behaviour was the thing to be corrected; the underlying causes of the behaviour were given less consideration.
Many parents of autistic children at this time judged ABA to be successful because it appeared to reduce behaviours associated with autism (avoidance of eye contact, stimming, non-verbalism, aversion to physical contact) while increasing behaviours that were regarded at the time as developmentally typical or socially adaptive (making eye contact, speaking, participation in group activities, etc).
The earliest forms of ABA employed praise and rewards for children who performed the desired behaviours, and also aversive techniques, including shouting, slapping, and electric shocks as punishment for undesired behaviours.
I want to make this clear, because often people find this difficult to believe when they come across it for the first time:
Early ABA routinely involved punishment of autistic children for non-compliant behaviour. These punishments included shouting into the child’s face, physical assaults such as slapping the legs or face, and using electric shocks. Lovaas actually used a room with a floor that had metal grids through which electric shocks could be delivered to children. This was not secretive abuse; the methods were openly discussed, and were famously reported as a success in a 1965 article in Life magazine. An image from a page in the article is below:
At the time, such brutal methods were considered acceptable by some behaviourists working with people who had developmental disabilities. Today, however, these practices are thankfully regarded as unethical and have been abandoned by mainstream ABA providers.
In 1987, Lovaas published a study that would profoundly influence autism intervention for decades. The paper reported that nearly half of the autistic children who had received intensive behavioural intervention achieved what Lovaas described as “normal educational and intellectual functioning.” School staff reportedly described these children as being “indistinguishable from their normal friends.” This term, indistinguishable, would later become one of the most controversial descriptions associated with early ABA.
Although the study was criticised for inadequate methodology, small sample sizes, lack of random assignment, and concerns about how the outcomes were measured, its findings were widely interpreted as evidence that intensive early intervention could dramatically alter developmental outcomes. As a result, ABA became established as the dominant therapy for autistic children.
Throughout the 1990s and 2000s, ABA became firmly institutionalised, particularly in the US. Health insurers and education systems began funding intensive behavioural programmes, and professional standards were formalised through the creation of the Behavior Analyst Certification Board (BACB).
Over the years, the practice of ABA underwent significant changes. Physical punishment was abandoned, although other negative reinforcements continued to some extent.
In recent years, ABA has become the subject of intense controversy. Increasing numbers of autistic adults who underwent ABA as children have described it as psychologically harmful. The focus was often on making children adopt behaviours that would make them appear less autistic, and suppressing naturally autistic behaviours, rather than helping them to live well as autistic people.
One of the most striking aspects of this controversy is not simply the disagreement itself, but what has historically been missing from the research. For almost sixty years, studies of ABA have focused primarily on whether children’s behaviour changes during or shortly after therapy. By comparison, remarkably little research has asked autistic adults a far more fundamental question: looking back on their childhood intervention, do they believe it improved their lives? Did it enhance their wellbeing, autonomy, and sense of self, or did it simply teach them to appear less autistic?
Modern ABA
Researchers have now begun paying greater attention to questions that earlier work on ABA rarely addressed. Alongside measuring changes in behaviour, there is increasing interest in long-term outcomes such as mental health, autonomy, informed consent, quality of life, and the experiences that autistic adults have reported. This shift has prompted many ABA practitioners to modify their practices and, importantly, the way they describe and market their practices.
Modern ABA practitioners now position the therapy as supportive of the autistic individual, encouraging behaviours intended to help the autistic child thrive. However, modern ABA still rests on the same underlying principles of behaviour modification, and success is still measured in behavioural terms.
The Conflict Over ABA
Regardless of how positive the descriptions of modern ABA are, the expectation of practitioners and parents remains that it will change the behaviour of the autistic child. Many autistic people will argue that this pressure to change will still ultimately cause psychological harm to the child, which might not fully manifest until adulthood.
Practitioners will counter that modern methods only use encouragement and positive reinforcement. However, this cannot take away from the fact that by its very definition, behavioural therapy is intended to change behaviour. Autistic behaviour, also by definition, comes naturally to autistic people. Therefore, even changes that occur through a process of positive reinforcement constitute pressure to suppress autistic behaviours.
This argument is countered by modern practitioners who say they will not suppress naturally occurring autistic behaviours such as stimming. In fact, practitioners often spend so much time explaining what they will not do, that one is entitled to wonder what, in verifiable specifics, they actually do.
Modern ABA literature often describes encouraging helpful behaviours without always specifying which autistic behaviours practitioners believe should change. This raises an important question: if behaviours are not expected to change, in what sense is the intervention behavioural therapy?
Many practitioners of modern ABA still claim the therapy is successful, as do many parents of autistic children who have undergone the therapy. But the measures of that alleged success are in the observed behaviour of the children. It is measuring compliance, with little or no regard for the internal psychological experience of the child.
Practitioners will claim that if the behaviour has changed, it is something beneficial that has been learned, and which the child can put to use in life. Autistic people and critics of ABA will counter that the changed behaviour is simply produced to gain the offered rewards, or to avoid the pressure and structured demands that are involved in the therapy.
Practitioners will say there is no pressure, only encouragement, but autistic people will say that simply being in the therapy environment, with its structure and persistent “encouragement” to adopt new behaviours, obviously constitutes pressure.
What is Therapy?
We know that modern thinking on autism is that it is not a disease or an illness, despite current diagnostic paradigms labelling autism as a disorder or condition. This contradiction is at the heart of the war of ideas currently being fought over autism, and, more widely, the neurodiversity movement itself.
The neurodiversity paradigm identifies autism as one of many neurotypes; a difference from neurotypical or the neuromajority. But all formal approaches to autism use a medicalised model. It is within this medicalised model that therapy is seen as appropriate.
For much of the twentieth century, the success of medicine was largely judged by whether it reduced or eliminated disease or disorder. The underlying logic was straightforward: There is a normal state of health. Disease or disorder moves a person away from that state. Therapy should move them back towards it.
This way of thinking has worked extremely well for many conditions. If someone has bacterial pneumonia, successful treatment eliminates the infection. If someone has cataracts, successful surgery restores vision: The therapy is judged by whether it changes the condition.
When autism began to be studied clinically, it was interpreted within the medical framework. Autistic behaviours became the “symptoms” that Lovaas and subsequent ABA therapists sought to resolve.
From this perspective, a reduction in stereotypically autistic behaviours (avoidance of eye contact or echolalia, for example) in an autistic child is simply evidence that the therapy is working. Therapists and parents, therefore, can justifiably claim that ABA works if they see the desired behavioural changes in a child. But as this pays no regard to the inner experience of the child, and the long-term effects on their psychological health, it opens a further question:
What Should THERAPY Be?
If the purpose of therapy is to move a person to a healthier state, and ABA primarily seeks to achieve change through observable behaviour, is it really therapy? This is not a scientific question about autism, but a philosophical question of the nature of therapy, and what should be included, or not included, in a medical paradigm. Should therapy merely change observable behaviour, or help a person live a healthier, more autonomous and more authentic life?
While science has yet to prove a causal link between ABA and PTSD, the lived experience and personal reports of psychological trauma from autistic adults who underwent ABA in childhood remain a grave concern.
Many autistic people would argue that a process which puts pressure on autistic children to behave in a way that is in serious conflict with their natural inclinations is the opposite of therapy; it actually causes harm. It is well-established, for example, that some autistic people who avoid eye contact experience sensations of physical pain when making eye contact. Some also experience pain from physical touch, such as hugging. It is difficult to see as helpful or therapeutic the process of pressuring autistic children to adopt behaviours that hurt them, especially if those children are unable to adequately explain what the problem is.
Autistic Masking and Burnout
The subjects of autistic masking and burnout have been covered in detail in earlier articles on this website. But for a brief reiteration, autistic masking is a self-imposed behavioural change in order to appear less autistic. This is usually done to facilitate social acceptance. It is widely accepted that long-term autistic masking (behavioural change) leads directly to autistic burnout, which is a debilitating condition affecting autistic people. Many autistic advocates now promote unmasking, encouraging autistic people to live as their true selves without forcing behaviours that do not come naturally. This is seen by many autistic people as a healthier approach to autistic life.
Critics argue that, where ABA encourages autistic children to suppress harmless autistic behaviours in favour of neurotypical ones, it may inadvertently teach masking. Masking is linked to autistic burnout and the accompanying psychological harm.
The worry regarding ABA, however light the supposedly therapeutic touch might claim to be, is that the child will comply with it to exit the pressure of the therapy environment (known as maladaptive compliance), and therefore be deemed a therapeutic success, before the psychological damage emerges later in life.
None of this is to deny that many autistic children genuinely acquire useful skills through behavioural teaching. All children undergo behavioural teaching, from parenting and so on. The question regarding ABA is whether gaining those skills necessarily requires encouraging children to suppress harmless autistic traits, and whether success should ultimately be judged by behavioural conformity or by the person’s long-term wellbeing.
The message to parents of autistic children considering putting their child into any kind of behavioural therapy (ABA now often goes by other names, as practitioners have become aware of the negative associations with ABA) is this: Outward behaviour does not equate to mental and emotional wellbeing. Autistic children grow into autistic adults, and many autistic adults report remembering ABA experiences as traumatic.
That’s all for this time. Take care.
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