September 2022 Edition!

A response to Gorycki, Ruppel, and Zane

In its most recent biennial update, the Centers for Disease Control (CDC) indicated that approximately 31% of children with Autism Spectrum Disorder (ASD) were classified as intellectually disabled. In addition, approximately 25–50% of children with ASD do not develop functional verbal communication (Patten et al., 2013). This subset of nonverbal children with autism who are classified as intellectually disabled were the subject of the review by Sandoval-Norton and Shkedy (2019) in which they discussed the use of Applied Behavior Analysis (ABA) on this population.

As described in Sandoval- Norton and Shkedy (2019, p.1) “[ABA] is a form of behavior modification that relies heavily on external reinforcement, both positive and negative (operant conditioning). ABA is intended to modify or diminish behaviors, as well as increase language, communication, social skills, attention, etc., in children with ASD. The main tenets of ABA follow behaviorist theories that suggest that behavior is caused by external stimuli in the environment, which is why a reward (external) would reinforce a behavior, and punishment (external) would discourage a behavior.” As ABA focuses solely on a behavior itself as opposed internal constructs (e.g., thoughts, emotions, pain) (Behavior Analyst Certification Board, 2021a, 2021b), Sandoval- Norton and Shkedy (2019) illustrated and cited research demonstrating how this can lead to psychological and physical abuse, and violates the ethical obligation to “do no harm.” Gorycki et al. (2020) published a response to Sandoval- Norton and Shkedy et al. (2019) in which they identified five criticisms of the original article and cited research which they alleged negates the premise of the original published article. However, the cited research does not predominantly apply to the aforementioned population and does not address the original criticism of ABA. … the following is a detailed explanation and additional research to show why the original research stands.

ABA is unethical and abusive Gorycki et al. (2020) argued against this point by discussing the Professional and Ethical Compliance Code for ABA therapists. They stated that “the ethical code mandates behaving in a way to maximize benefit and minimize harm. Practicing outside one’s scope is unethical. Practicing incompetently is unethical. Instead, behavior analysts create treatment plans based on the client’s needs, as dictated by the client and his/ her significant others.” (Gorycki et al., 2020, p.3) The issue is not whether or not ABA therapists follow their own ethics code; the issue is the ethical scope of the practice of ABA, given that the practice of ABA inherently ignores all internal constructs. Ivar Lovaas, who is revered as the father of ABA, spent the majority of his life expanding and utilizing behavior modification (Smith & Eikeseth, 2011). All of his applications of behavior modification were consistent with the Professional and Ethical Compliance Code for ABA therapists. In the 1970s, Lovaas utilized behavior modification to treat young boys who displayed feminine characteristics. Lovaas believed these feminine “manifestations are indicative of later adult sexual abnormalities, e.g., transvestism, transsexualism, or some forms of homosexuality” (Rekers & Lovaas, 1974, p 173). Lovaas conducted various studies attempting to change these behaviors, despite lacking a basis or understanding of what he believed were sexual abnormalities (Rekers & Lovaas, 1974; Rekers et al., 1974; Rekers et al., 1977). …

Thus, the issue at hand is threefold: (1) what behavior is inherent and appropriate, (2) what expertise is required to make such a determination, and (3) what expertise is required to recognize when the treatment is actually causing harm. … At its core is an inherent requirement that necessitates a therapist’s understanding of the internal processes and abilities of the patient before designing a treatment plan, as well as the training to recognize when the treatment is detrimental. ABA therapists are not required to take even a single class on autism, brain function, or child development (Behavior Analyst Certification Board, 2021a, 2021b). … it is negligent, dangerous, and malpractice for any professional or paraprofessional to claim expertise and implement interventions for a group they have not vigorously studied. …

Gorycki et al. (2020) stated in their response that “autism is a neurological disorder” (p.1). This statement is factual, and there is no disagreement here. However, we are compelled to point out that while the acknowledgement is proper, in theory and practice, ABA does not treat autism as a neurological disorder. ABA is far more concerned with outward manifestations of behavior and the treatment of those manifestations, which is a very far throw from anything that could be considered neuroscientific. … in courses required to become a BCBA, nothing exists that could be considered even tangential to neuroscience (Behavior Analyst Certification Board, 2012). …

Gorycki et al. (2020) also defended ABA’s approach to … “self-stimulatory behaviors.” It is unclear if they are referring to true self-regulatory behaviors or maladaptive and/ or self-injurious behaviors. This is an important distinction, as research indicates that certain self-regulatory behaviors serve to regulate and calm, and as such it is vitally important to distinguish between the two types of behaviors (Baron et al., 2006; Brenner et al., 1947; Tomchek & Dunn, 2007; Tomchek et al., 2014; Shkedy et al., 2019). … forcing a child to stop these soothing behaviors is largely harmful, and unhelpful. We hypothesize that the only reason that ABA attempts to “extinguish” such behaviors is, generally, to make neurotypical people more comfortable. …

Additionally, Gorycki et al. (2020) cited that the ethical code obligates behavior analysts to refer a client who is not making progress to another professional who might be more successful. … The client may be making progress on goals that will actually harm them in the long run. Going back and forth between “professionals” who are not trained to treat the disorder at hand is unlikely to help. … Regardless, of the specific types of behaviors the authors referred to, Gorycki et al. (2020) essentially stated that ABA is successful at reducing whatever behaviors the “consumer” wants. The fact that ABA is consumer-based instead of neuroscience-based or client-centered is very problematic. We are unaware of any other healthcare profession where the patient or parent runs the treatment. …

We are attempting to highlight a non-verbal, highly vulnerable population that deserves to be especially protected by the professionals serving them. Under ABA’s consumer-driven model, the dignity of the child is not taken into account. … Furthermore, Gorycki et al. (2020) did not address self-injurious behaviors in autism and the failure of the Functional Behavior Assessment (the bedrock of ABA) to address these behaviors. Shkedy et al. (2019) demonstrated that self-injurious behaviors in non-verbal children with autism are a cry for help due to their lack of communication skills; ABA therapists overwhelmingly predominantly denote these behaviors as task avoidance. It is precisely because of their lack of training in human psychology that they reach these erroneous conclusions that inevitably cause harm to their clients with autism. … Shkedy et al. (2019) demonstrated that there is a plethora of research showing the oversensitivity the autistic brain has to external stimuli with some of them actually causing physical pain. Basic knowledge of these constraints would lead a therapist to avoid stimuli that are torturous, instead of taking on the false assumption that a child is attempting to escape or avoid a task and then continuing to expose them to the offending stimuli. This only results in a therapist forcing the non-verbal child to endure further torture. We must emphasize that ABA therapists and associations present themselves to the government and the public as autism experts. …

Representing oneself as an expert in a subject one has no knowledge of is usually considered fraud, at least once revealed. At its very core, it is the epitome of unethical action. The growth of the neurodiversity movement in autism is a direct result of the practice of ABA on the autism population. It was the attempt to fix “that which may not be broken” that led to this revolt. … We are not the first authors to emphasize the abusive nature of ABA therapy, and various others continue to identify this abuse and advocate for the termination of this abuse or for alternative treatments (Hungate, 2020; McGill and Robinson, 2020; Milton, 2020; Robinson et al., 2020; Wilkenfeld and McCarthy, 2020). Wilkenfeld and McCarthy (2020) demonstrated that ABA is unethical from a bioethics perspective. …

Finally, Gorycki et al. (2020, p.4) stated that “Sandoval- Norton and Shkedy (2019) claimed that the practice of ABA is unethical due to the exclusive use of behavioral procedures.” They then cited research to show that “students served by intensive ABA have significantly better outcomes (IQ scores, language scores, etc.) than those children who are educated with various non-ABA approaches.” Firstly, the exclusive use of behavioral procedures implies ignoring all the internal processes and as shown above, is what leads to the unethical treatment. Secondly, citing research on a different population group does not validate the argument. Any study that uses IQ as a measure of improvement … has excluded nonverbal children with autism since they notoriously do not have any measurable IQ. In clinical experience with hundreds of nonverbal children with autism, not one had a reported measurable IQ on any previous psychological evaluation. …

ABA promotes prompt dependency …Prompts can be physical, verbal, visual, and even the presence of a paraprofessional can serve as a prompt. Prompting is used as a teaching technique in various fields. The goal is to discontinue prompts as the learner begins to engage in the task independently. ABA’s stated long-term goal of fading prompts and improving independence are acknowledged. However, the methods utilized in ABA are fundamentally unsound for treating the severe autism population. Despite multiple decades as the most preeminent approach for treating those with severe autism, there is no research to support prompt fading actually occurring in this population. The research cited by Gorycki et al. (2020) suggesting prompt dependency is uncommon has many flaws. … This is likely due in part to the fact there is not very much research on this subset of autism (the main point of the original publication). Still, this population is forced to engage in these same interventions, perhaps more often than the non-severe population, despite these studies occurring without them as a primary participant. Many of them have ABA imposed on them over nearly their entire lifetime …

Furthermore, research indicates prompt dependency is a very prevalent problem, even in “higher functioning” individuals (Wilson et al., 2014). … If prompt dependence was only caused by “bad” therapists, one would not expect a plethora of published research about remediating/reducing prompt dependence. … ABA only works for children with particular characteristics of autism Sandoval-Norton and Shkedy (2019) … stated that there is no research indicating that ABA works for nonverbal children with autism. Practitioners of ABA and Gorycki et al. (2020) point to two metastudies as proof that ABA is effective for treating autism (e.g., Peters-Scheff er et al., 2011; Virués-Ortega, 2010). The majority of studies in both of these meta-studies were actually discrete trial training (DTT) and the version of DTT that uses aversives (e.g., electric shocks) to punish behaviors, called the Lovaas/UCLA model. While there are ethical issues involving both of these methodologies, excluding them from the meta-studies begs the question about the efficacy of non-DTT ABA therapy as a treatment for autism. One of the consequences of the neurodiversity movement was the new wave of a “kindergentler” approach to ABA that excluded the use of DTT and the beginning of the use of Natural Environment Teaching. However, these new approaches contain no scientific support from the much quoted meta-analyses, regardless of the ethical implications of long-term ABA as discussed.

two major studies conducted by the US Department of Defense over a nationwide sample in the last two years massively call into question the efficacy of ABA for treating autism. These studies were based on real world experience and not laboratory results. In addition, the sample size for both was over 6000, making them the largest studies these authors are aware of pertaining to autism services. … While the data from the US Department of Defense did include nonverbal children with autism, research presented by Gorycki et al. (2020) and nearly all research on ABA does not pertain to this subset of autism. … As mentioned above, this is because one common characteristic of this population is the inability of professionals to measure their Intellectual Quotient (IQ). … Gorycki et al. (2020, p. 6) also cited that “[p]rofessionals in behavior analysis employ numerous alternative communication methods for those individuals with verbal deficits.”

They continue to state that “[i]n deciding which method is best, behavior analysts determine what type of communication is likely to provide the most influential impact in the shortest amount of time.” While there is agreement that nonverbal children do need alternative means of communication, these comments are just more evidence of practicing outside one’s scope. … ABA includes methodologies that are considered “out of date” and ineffective The Association for Behavior Analysis International asserts that ABA is a natural science comparable to physics and biology (International Association for Behavior Analysis, 2019). According to the Merriam-Webster.com dictionary (2021), a natural science is one that deals with objectively measurable phenomena. While this may be true for some behaviors, there are many behaviors resulting from internal processes that are not objectively measurable.

A simple example is that there is no reliable objective measure of how depressed or angry a person is, and this leads to the conflict between human psychology and ABA. It is this lack of understanding of the human psychology and the lack of scientific rigor that leads to the malpractice of ABA. The cornerstone of ABA is the Functional Behavior Assessment (FBA), which is used to hypothesize the function of a behavior in order to treat it. Behaviorists believe that all behaviors demonstrated by all people serve a function and have a purpose. Behaviors are meant to either obtain something desirable (e.g., attention, money) or to avoid or escape something unpleasant or punishing. As a result, the most common “functions” used in a FBA are positive/negative attention, task avoidance, and escape. However, to scientifically prove a function causes a behavior, both variables need to be measurable. To prove that a child is indeed using a behavior for negative attention, both the behavior and the negative attention must be measurable. To attempt to do otherwise is conjecture and violates the requirements of a natural science. …

Gorycki et al. (2020) objected to the criticism that external reinforcement does not work in the long-term and creates psychological ill-being. They cited Cameron and Pierce (1994) to claim that external rewards do not impinge on intrinsic motivation. However, Kohn (1996) illustrated that there were failures in methodology and inclusion of evidence that led to these erroneous results. Cameron et al. (2001) made the same errors (Deci, et al., 2001). … The consensus is that crowding out reliably occurs under the following conditions: (1) rewards are offered in the context of pre-existing intrinsic motivation (for interesting tasks or pro-social settings), (2) rewards are known in advance and expected, and (3) rewards are tangible. … In order to ameliorate any of the symptoms associated with autism (communication, social skills and repetitive behaviors), it would require the child to perform tasks that require creativity, problem solving, and concentration. Per research, this is suppressed by external incentives, so there is no reason to believe that this amelioration occurs, and again, no legitimate proof is offered to show dampening of symptoms associated with ABA in those with severe autism.

ABA has no data showing its effectiveness over the long-term … Gorycki et al. (2020) chose research that does not pertain to the population discussed by Sandoval-Norton and Shkedy (2019), additionally, even the research chosen does not discuss long-term use of ABA. They seem to have confused following up in the long-term with long-term use of ABA. They do not present any longitudinal studies that shows what occurs when someone receives ABA day in and day out for 5, 10, or 20 years. … Research on the effects of prolonged, long-term use of ABA is sorely lacking. …

Proponents of ABA continue to argue that their archaic approach to human behavior is suitable for the most vulnerable autistic population, though it is no longer used in the wider human population. Despite decades of usage as the primary method for this population worldwide, ABA has never been shown to be even slightly efficacious for this population. … not a single argument, response, or rebuttal has included any neuroscientific research. … That a group of practitioners can state that “autism is a neurological disorder” at the very beginning of a paper and go on to cite zero neurological research and zero neurological basis for their claims about a supposedly efficacious treatment for autism could be considered by some as the very definition of “cognitive dissonance.” Research in ABA continues to neglect the structure of the autistic brain, the overstimulation of the autistic brain, the trajectory of child development …

Read full paper by Aileen H. Sandoval-Norton, Gary Shkedy & Dalia Shkedy: