To What Extent Should We Train Autistic Kids to Be Normal?

Editor’s Note: This article previously appeared in a different format as part of The Atlantic’s Notes section, retired in 2021.

A new piece by Elizabeth DeVita-Raeburn on the use of “applied behavioral analysis” (ABA) is eliciting a lot of strong response from readers. ABA—“the longest-standing and best-established form of therapy for children with autism,” according to DeVita-Raeburn—was developed out of the behaviorist school (think B.F. Skinner and his use of rats and food pellets); it breaks down desirable behaviors into discrete steps, rewarding a child for completing each step along the way and discouraging errant behaviors.

But the popular method is controversial among a subset of autistic adults, advocates, and parents of autistic children:

They contend that ABA is based on a cruel premise—of trying to make people with autism ‘normal,’ a goal articulated in the 1960s by psychologist Ole Ivar Lovaas, who developed ABA for autism. What they advocate for, instead, is acceptance of neurodiversity—the idea that people with autism or, say, attention deficit hyperactivity disorder or Tourette syndrome, should be respected as naturally different rather than abnormal and needing to be fixed. ...

[Lovaas’] approach discouraged—often harshly—stimming, a set of repetitive behaviors such as hand-flapping that children with autism use to dispel energy and anxiety. The therapists following Lovaas’ program slapped, shouted at, or even gave an electrical shock to a child to dissuade one of these behaviors. The children had to repeat the drills day after day, hour after hour.

This illustrative video of Lovaas methods from 1981 does not contain slapping or electrical shock, but it does display a range of other techniques such as stern repetitive directives, food reinforcement, and the stopping of stimming:

(Here’s a much more contemporary video of an ABA session.)

In the comments section of DeVita-Raeburn’s piece, Suzanne Letso, the co-founder and CEO of Connecticut Center for Child Development, defends ABA against criticism, especially regarding its roots: “ABA programs have evolved and improved since the early work of Lovaas and others.” She continues:

Unfortunately, this article is very misleading about what ABA is and is not. ABA programs utilize positive reinforcement, not aversive practices, to change behavior. ABA programs customize intervention for each learner and make learning fun, not punishing.

ABA is not synonymous with DTI [Discrete Trial Training—a method of teaching in simplified and structured steps]. ABA is not just a treatment for autism. ABA is not a package of static programs. People interested in learning more about what ABA is and how it can be utilized … please go to apbahome.net or bacb.com or casproviders.org or balcllc.org

Another reader also attests to the evolution of ABA since the Lovaas days:

I’ve worked with hundreds of kids and adults on and off the spectrum for over 15 years using the principles of ABA; “unrelenting drills” were never used. I’ve taught kids skills such as sledding with their peers in their neighborhoods, eating at a restaurant for a grandma’s birthday, and clapping their hands to get attention instead of punching somebody or themselves. This article also shines little light on the thousands of studies that support ABA interventions in schools, homes, work places, and communities.

A parent of an autistic child is on the same page:

We have my 6-year-old daughter in ABA therapy 20-30 hours a week. She’s improved immensely, and they don’t use any aversives.

They do, however, keep insisting that she follow directions, but it’s more in the sense of repeating the same command over and over again in a consistent tone until it sinks in that she’s not going to get her way by throwing a fit. (When we first started, she was 3 and would sometimes scream, hit, or run away if the therapist wanted her to stay in her room, pick up her toys, of follow some other direction.)

For a while, food was used as a positive reward, but she was never rewarded like this when she was hungry. (Now, the reward is watching Frozen videos or doing a preferred craft for 10 minutes.) Her speech has improved immensely and she’s able to successfully engage with her peers and school and out around town (the park)—something I never thought would happen.

Maybe a good way to think about this would be to compare old-style ABA therapy to standard parenting practices from the same time period. Most of the practices from that era on both fronts would be considered abusive now. Hitting your kids with a belt, sending them to bed without dinner, etc. were all common at that time.

We try to shape our children, neurotypical or not, to be aware of social norms/behaviors. That doesn't mean we don’t value who they truly are. Well-applied ABA therapy just tailors that approach to an autistic child’s needs.

One more reader, Hannah, makes a distinction about how ABA can and should be used:

Most of the criticism here seems to be directed at ABA therapy targeted at social skills. I can understand this, though I’m not sure that the people regretting their treatment would actually have been better off without that treatment. Still, impossible to say.

But ABA is also teaching children to eat and communicate and use the bathroom and get dressed. It’s teaching them the basics of independent living.

As someone who works in a home for adults with various types of disabilities, including several women who are recipients of ABA therapy, while I feel somewhat uncomfortable with several aspects of how therapy is done, I still see it transforming people who are functioning at a much lower level than the people in this article who will never in a million years be “neurotypical” but who, by learning life skills, can live a life with dignity and with more independence than otherwise. It also makes it much easier for the caregiver as well (though that may sound heartless).

Bottom line: Purely social ABA for high-functioning people with autism may be potentially harmful, but don’t throw away the baby with the bath water.

If you have any firsthand experience with ABA and want to shed some new light on this discussion, please let us know: hello@theatlantic.com.