100: The Controversy of ABA: A Discussion with a Psychologist
In this episode Psychologist Lesley PsyD discusses Applied Behavior Analysis (ABA) therapy, particularly in the context of autism, during Autism Awareness Month. This conversation aims to provide a neutral and factual overview of ABA, exploring its principles, applications, and the diverse perspectives surrounding it. Lesley explains ABA's focus on understanding and modifying behavior through reinforcement and environmental adjustments. They address the benefits and risks of ABA, emphasizing the importance of individualized approaches and naturalistic learning.
Show Highlights:
Overview of Applied Behavior Analysis (ABA) therapy and its relevance to autism.
Clarification of ABA terminology and its practical applications.
Discussion of the emotional and controversial nature of ABA therapy.
Examination of the challenges parents face in accessing appropriate therapies for children with autism.
Importance of understanding behavior in context, including antecedents and consequences.
Exploration of the benefits and risks associated with ABA practices.
Critique of the focus on compliance and neurotypical standards in ABA.
The role of reinforcement in behavior modification and its implications for intrinsic motivation.
Discussion of the need for individualized approaches to therapy that respect children's unique experiences.
Advocacy for a compassionate and nuanced understanding of autism and behavior analysis.
Resources and Links:
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Automatically Transcribed With Podsqueeze
KC Davis 00:00:05 Hello, sentient balls of stardust. Welcome to Struggle Care. I'm your host, KC Davis. And welcome to the best worst little podcast. I sometimes see people on TikTok and they have, like, clips of their podcasts, and they're sitting in, like, real studios with, like, makeup on. And, like, I'll talk to other people that have podcasts and they'll be like, oh, I'll have my assistant and my producer and my this and my that talk to you. And I'm like, I am still a lady in a closet. It's it's such an amateur hour here. And I hope that you guys still enjoy enough of the content that you'll stick around. For my amateur hour, I'm here with Lesley, my favorite psychologist. By the way, do you consider yourself a child psychologist? No.
Lesley PsyD 00:00:44 I mean, that's a good question. Actually. Not necessarily. My training is clinical, so it's all over the lifespan. I, I tend to focus on issues related to kids, but actually because of that, I work a lot with adults, so I don't know what I am.
Lesley PsyD 00:00:57 I'm just here existing.
KC Davis 00:00:59 Well, I'm so glad you're here and you're one of my favorite guests. And as you know, it is Autism Awareness Month. And I just wanted to do a quick little chat about ABA therapy. I'm going to get into it with some other people, but I just it's such a big topic, and it is such an emotionally charged topic that I want us to just sort of like, lay out what it is in a very like, matter of fact, neutral way so that people have an understanding of what we mean when we say ABBA therapy. so that some of the opinions and perspectives that I'm going to present later will make more sense. And so that's kind of our goal here. Are you up for it?
Lesley PsyD 00:01:48 That sounds great.
KC Davis 00:01:49 Okay. So first, can you regale us with your expertise in this area? Sure.
Lesley PsyD 00:01:55 So as a part of clinical psych, which is just our fancy way of saying, I learned about all the different parts of psychology before specializing, we talk about the different lenses that we can look at behaviour or existence through.
Lesley PsyD 00:02:09 And so some people would look at things through this lens of like understanding your earliest relationships. And some people would look really at emotions. And in the process of my training I did a lot of work understanding behaviour. So I started in neuropsychology, understanding brain based behaviour. And then I worked actually in ABA. Now I worked a long time ago. It's a very different field back then, but I worked in ABA both one on one with kids, and then I went on to supervise other people who worked with kids. I did that for about 8 to 10 years somewhere in there.
KC Davis 00:02:43 And then also, I think I feel like this is relevant, like somewhere along there. You also have worked closely with people doing like special education and IEPs. And even I think you said you were also like an expert witness. Tell me about that.
Lesley PsyD 00:03:00 Yes. That makes me sound very fancy. you are so fancy. In the process of doing all of my neuropsychology training, what really ended up happening is most of the kids that I was working with were also interfacing in the educational system, so they were coming to us for testing, but they needed someone to then explain what we were finding with their schools and with their families.
Lesley PsyD 00:03:21 And so over many years, I got a lot of practice working inside of schools, so on teams, working with special education teams. And then for a few years, I really hyper specialized in working with families who had had difficulty getting their children's needs met. And so we're now in litigation. They had lawsuits pending against schools. And so I would learn about a case, a situation that was happening with a child and all of their history. And then I would make some expert witness recommendations to the court. And I did that for about five years.
KC Davis 00:03:54 Excellent. Okay. So what is ABA.
Lesley PsyD 00:03:59 That sounds like such a deceptively simple question. So we'll start there. So ABA stands for Applied Behavior Analysis and it is exactly what it says. It is the applied version. So the real world version of a field of psychology called behavior analysis.
KC Davis 00:04:15 So behavior analysis is a theory like a way of thinking about something.
Lesley PsyD 00:04:24 Yes.
KC Davis 00:04:24 Is that what you're saying. And applied behavioral analysis refers to the techniques of how that, like theory turns into an actual therapy that gets delivered to people.
Lesley PsyD 00:04:40 That is correct. Yep.
KC Davis 00:04:42 Can you give us a is there a metaphor that that people at home might be more familiar with using other kinds of like therapy language?
Lesley PsyD 00:04:51 That is a great question. in terms of something being like a theory and then applied.
KC Davis 00:05:01 Oh, we thought about one like, like what's what's the theory where we talk about, like how the brain processes trauma, like literal, like the physical places in the brain and like, having to, like, reconnect neurons and things like that.
Lesley PsyD 00:05:16 So there is a theory actually, this is I don't know if this is what you're talking about, but I'm gonna talk about neuroplasticity. So neuroplasticity is is an idea is a thing that we understand is happening where if you have an insult or a trauma to the brain or an emotional trauma that we used to believe that that was use it or lose it. So if those neurons are or pathways are damaged, you're done. That's it. And over time we've learned that actually that those patterns can regrow.
Lesley PsyD 00:05:42 So that would be an idea process that we see. But when we want to say, well, how do we what do we do about that in real life, then we move into things that we can do with children to encourage neuroplasticity or post-traumatic growth therapy that can encourage us to reconnect. so it's a way to take that idea and then apply it.
KC Davis 00:06:01 So like, would eMDR be an example of like. It's based on the ideas in like neuroplasticity theory. But then there's this like specific technique in eMDR where you sit down and there's like a light and the person puts the light back and forth and like your your eye follows the light and you may or may not talk about traumas. And is that kind of like a decent enough metaphor?
Lesley PsyD 00:06:30 I think so, and I think that that's a great way to think about it, too, because eMDR as a practice is something that is very specific and it comes from this larger concept, and that is what we talk about with behavior analysis, where behavior analysis actually is a huge field of research and thought and theory.
Lesley PsyD 00:06:51 But ABA is a very narrow scope of procedures and activities that are done with a therapist.
KC Davis 00:07:00 And I think that's important because when you hear someone talk about like, does ABA work? Or maybe they have criticisms of ABA, I oftentimes feel like people don't necessarily get specific about what it is they're criticizing. Like are they criticizing the practice of ABA or are they criticizing like the theory behind how and why people work according to like, behavior analysis theories?
Lesley PsyD 00:07:30 Yeah, I would agree. And I also think that that's not people's faults either. One of the challenges with ABA is that it is we don't think of it in this way, but it is relatively young in the scope of therapies. It's not that old. And ABBA is still growing and changing, and so is applied very differently depending on the individual circumstances. The company you work for, the philosophical lens through which they view things. And so it can be really hard to talk about it. And I think that's why this conversation is so helpful. And it is important if people have criticisms or positive things they want to talk about with ABA to be incredibly specific, because it's a really big umbrella.
KC Davis 00:08:14 And I think one of the most important reasons why this is important is because, I mean, the reality is there are a ABA is like what was quoted to me right when we got our diagnosis, it's like, this is the number one therapy for autistic kids, and it's often one of the only therapies that insurance will cover. And even when insurance covers things like speech therapy and occupational therapy, those are typically 1 to 2 to three hours a week, whereas private insurance companies will cover sometimes up to 40 hours a week of ABA. Yeah. And what this means is that if you are a parent and you have to work to live, but your child is disabled in such a way that private preschools will not take them and they are not old enough for public school. It may be that the only choice that you have in order to pay your bills is to find an ABBA center for your child to go to as a form of child care. And so I think that that's important to keep in mind for the audience and for everyone listening.
KC Davis 00:09:32 And and people have really strong feelings about it. And there are people that have had their own personal experiences with ABA that are positive. And a lot of people that have had personal experiences with ABBA that are really negative and and might feel some trauma about it and might feel very activated and triggered by conversations about how to engage with ABBA. And so I just like to put that out there. That part of part of discussions about psychology and therapies is like what I call like coffee house talk, which is just like, yeah, it would be great if we did this and it would be great if we did that and this, that and the other. But then, like, it's very different when you look at it from a harm reduction standpoint where you look at like, okay, but if a person has no other options, how do they reduce harm or how do they get the best experience and things like that? So I just wanted to throw that out there. Okay. So if you had to teach me what like the theory of behavioral analysis is if you had a cliff note for me, what would you say?
Lesley PsyD 00:10:28 So that's another great question.
Lesley PsyD 00:10:29 So behavioral analysis always starts with with the basics of how we think behavior is initiated and maintained. Increase or decrease. And remember as we're talking about this, this is a lens through which you can view behavior. This is no longer even the way that I the lens that I use at work. But it is one of the lenses through which we can view things. So in basic.
KC Davis 00:10:52 What do we mean by behavior by the way?
Lesley PsyD 00:10:54 Yeah. So. And everything. Everything. If you're if you're alive, if your heart is beating, you're behaving. I think that's also one of the things that can make it challenging for new parents of newly diagnosed kids to understand what we're talking about in this area, because Ava has its own language, they have their own terms and their words that we use, but they don't mean the same thing. So in that case, behavior is really anything an organism does. And there are also, you know, internal behaviors, including thoughts and feelings and emotions.
KC Davis 00:11:27 Weight, thoughts and feelings are considered behaviors.
Lesley PsyD 00:11:31 Depending on the field of behaviorism that you were to ask. There are some folks that are pure behaviors that would say something has to be observable to be a behavior for an organism to engage in a behavior. But there are lots of fields within behavior analysis that include everything in all the internal experiences as well.
KC Davis 00:11:53 That makes sense to me. I do remember one of the first things I learned was like, you know, so you have like a kid sitting at a desk and he's like jumping up out of the desk and he's standing up, I think. Calling that a behavior like the behavior of standing up is like, yeah, of course the behavior. But what I had to learn was that, like the kid not standing up is also a behavior. Like, that's the behavior of not standing up, the behavior of sitting. And so it's like the not doing something is just as much of a behavior as the doing something.
Lesley PsyD 00:12:26 Yeah. And if, if we can skip ahead and then come back for a second, that's one of the keys to knowing whether if, if your best option is utilizing an ABA service, providers that understand that are one of the biggest green flags, that not all behavior is easily observable.
Lesley PsyD 00:12:47 And we will have to kind of enter into the experience or try to connect with the experience of the child that you're working with. Viewing children in this very black and white manner of only behaviors that are observable matter is falling out of favor, even within behavioral circles. But if we're thinking about it in that way. To start, the idea behind behavior analysis is that some behavior changes frequency or intensity and goes up and some goes down. And the reason that that happens is the things that come before that behavior and the things that come after. And basically these series of events that happen a million times a day are slowly shaping our behavior and developing patterns. And sometimes the patterns that we get into are not helpful to us. And it would be helpful to change that pattern by changing what comes before or after. That's the cliff notes.
KC Davis 00:13:43 Okay, so if a kid is standing up from their desk over and over and over and over, then that lens would say, okay, the behavior is standing up over and over and over and that whereas some other fields of psychology might focus more on, they stand up because when they were a child, standing up was the best way to get their mother's attention.
KC Davis 00:14:03 Right? Or they're standing up because, you know, they went through something traumatic and the neural pathways are now, you know, standing up is this response whatever. But when you look at it through this lens, it's interesting because you could obviously use more than one lens at a time, like kind of like an overlapping microscope. But this lens would say the kid is standing up because something happened right before that action that led to the standing up. So the kid felt restless, and so they stood up, or the kid felt uncomfortable, so they stood up, or the kid wanted to had to go to the bathroom. So they stood up. Is that kind of.
Lesley PsyD 00:14:44 Part of it? Yeah, that could be one of the more theoretical lenses to view it through in behaviourism. And ABA practitioner would do even more. So they would take data. So ABA is incredibly data centric and focused, which we could talk about has positives and negatives to it. So the the ABA practitioner might observe that child in that class for seven days, and they might make little tick marks whenever that child was standing up and they would say, what is the pattern? I'm seeing what's coming right before standing up and what happens as a direct result.
Lesley PsyD 00:15:15 And so maybe what we're going to see is that the child is only standing up out of their seat in math and is only standing up in their seat in math two minutes before the bell goes off. And when they stand up, the teacher is doing something or saying something, and then the next day they stand up even sooner. So now we're seeing a pattern of there's something called an antecedent that's coming right before. And in that case, it would be something about being in math or being right close to the end of the bow, and then something's happening afterwards to make that behavior more, frequent. And we would say that that's reinforcing that behavior because it's making it happen more often. So if we don't want to see that, then we would have to break that chain somehow.
KC Davis 00:16:02 Okay. All right. So that makes sense. It's sort of like I've always heard people talk about. It's like this. It's a theory about how people learn. which is confusing to a layperson's ears because we think of learning as like learning facts.
KC Davis 00:16:19 Yeah. but when we talk about how people learn in an applied behavioral analysis perspective, we're talking about how people learn to choose behaviors, right?
Lesley PsyD 00:16:30 We're yes. And we're we're talking about learning that is happening outside of the awareness of the person. We're talking about learning and context, more modern applications. So that was really simplistic way to look at it. More modern applications in behavioral science take into account a bunch of things, including like what is the evolutionary benefit of this behavior and what language has become a cue for that behavior. So one of the ways to think about how ABA views behavior is almost like math equations. They very much will view things as discoverable patterns that we can figure out and change. And that's a very unique, different way compared to other parts of psychology, which would maybe talk about we need to connect so that kids can get their needs met. we're not necessarily trying to hack the puzzle. ABBA is very much about figuring out that puzzle and breaking that chain.
KC Davis 00:17:27 So like, if I'm trying to potty train my child and I'm noticing that, like, they're not getting it, they're not getting it, and they're not getting it.
KC Davis 00:17:37 And in some ways, do we as parents or teachers, kind of like intuitively sometimes do this where we're going, okay, well, you know, maybe it's because they're still wearing the diaper, maybe wearing the diaper, like, prevents them from like learning to go to the potty. And so like, let's change this antecedent of like, wearing the diaper. And then we look at the back end and we go, well, what if we changed the reinforcement. And we had a sticker chart where they got a sticker every time they went to the potty. And maybe if we changed this antecedent and this reinforcement like that would change this middle behavior of like going potty in a diaper versus going potty on the potty.
Lesley PsyD 00:18:14 Yeah. And that's another way of talking about that. Behaviorism is not necessarily doing something different. It's about viewing what's already happening in a different way. So behaviorists or ABA practitioners would view What you're doing through their own lens. So they would break down that sequence and say, great job, mom here.
Lesley PsyD 00:18:37 But what we're noticing, I'll give you a really good example of how this happens. My oldest daughter, who would be horrified if I if she knew I was telling you this story, or maybe not when she was potty training, was super into princess things and she was too small to get up on the potty. So I bought her a princess potty and the first time she went in there, she was so excited. And then she was going to go in there when she used the potty. I didn't know that the potty made a loud fanfare noise yay! When you actually went potty! So she went willingly on to the potty, went to the bathroom, and when that loud noise happened, she was horrified, jumped off off the potty and didn't go back on it for another three months. So there's lots of ways to look at that. But an ABA practitioner might say she engaged in a target behavior, a behavior we want to see sit on the potty. But what happened afterwards was a punishing event.
Lesley PsyD 00:19:33 So something happened and it made that behavior go down in frequency. So it's just their way of viewing it. So they would say, if we want her to go back to the body, we might have to provide reinforcement for smaller steps. Like she came in the room. Great job. Little sticker or praise. And then we might have to shape that behavior back up and also take the batteries out of the body.
KC Davis 00:19:55 Okay, so I have two questions. And I don't want to forget either one of them because I want to ask you what are some of the like, positives to that kind of thinking about behavior and then like what are some drawbacks or what are some things we could miss about that kind of thinking. And then but the first thing I want to ask is that so if thinking that way about getting my kid to go to the potty is thinking through a lens of behavior analysis, does that mean that the act of taking off the diaper and using a sticker chart is me doing ABBA with my child?
Lesley PsyD 00:20:33 That depends on who you ask.
Lesley PsyD 00:20:35 So one of the challenges about communicating about ABBA is that an ABBA practitioner would likely say everything is ABBA. That's a very common thing we hear from that field. In my opinion, no, because ABBA itself is is an actual skill that you have to get training on. And it's a it's not just doing a thing, it's about taking data. It's about understanding the reason you're choosing a procedure and measuring change. So it's not really doing ABBA, but someone might look at that and say, well, you're using the principles of behavior analysis. And in that case we you know, I guess we all are all the time.
KC Davis 00:21:16 And it's funny that we picked eMDR as our metaphor earlier because this fits right in. I actually read the other day that when you experience a traumatic event or a high stress event, one of the best things that you can do is as quickly as possible, go and play Tetris. Because there's something about the way that the game of Tetris causes your eyes to move. that stimulates that, like neuroplasticity in the two parts of your brain sort of talking to each other.
KC Davis 00:21:49 And it's similar to the same types of things we're trying to accomplish with eMDR. Right? Interesting. So, to me, that kind of lays over perfectly where it's like, okay, so is going to do Tetris, doing something through the thinking lens of neuroplasticity? Yes. Would we ever say that playing Tetris is doing eMDR? No, no. You have to go through so much certification to do eMDR because it's a very technical thing. And it's not just like this intuitive, I understand this, so I'm going to go do this like it's very technical. you have to go through certain phases. You have to have certain markers and feedback and all those sort of things. And so I kind of feel like that's a good like just because you're making informed decisions based on a way of thinking about something doesn't mean you're engaging in like the therapy of that thing. Yeah. So I feel comfortable saying like when people say everything is ABA that I, I, I'm going gonna, I'm gonna rule on that and say, no, it's not okay.
KC Davis 00:22:58 So that's helpful. So that's the way of thinking about things. So what are the positives or what can be helpful about thinking behavior in this way? If we have and we can use some real life examples if we if we have a child, an autistic child that is running into the road or we have an autistic child, that is, you know, not making eye contact or an autistic child who is maybe hitting themselves, or maybe they, you know, won't sit down in a classroom environment. Those are just going to throw out some behaviors there. I have no commentary on those behaviors except that they are behaviors. What are some helpful things that could come from thinking that way? And what are some risks that could come? Yeah.
Lesley PsyD 00:23:43 And I think this perhaps may be one of the most important questions we talk about, because we often don't slow down and had to have this conversation in public forums. In my opinion, the most positive thing about thinking in this way, especially about children's behaviors, but also about adults, is that ideally it takes blame and shame out.
Lesley PsyD 00:24:06 So it removes the idea that what's wrong with you? Why would you do this? It takes that away and it says every behavior makes sense. Everything is adaptive. The reason things happen is because they've been set into motion to happen. And so if we want them to be different, we don't lambaste the individual. We change the environment to assist them to get to where they need to go.
KC Davis 00:24:32 So this is you know, it's not that they're a problem child, right? It's not that they're disrespectful or rebellious. It's not that, you know, and I also can see where people get tripped up on like the word punishment because like it that has a very technical therapeutic term, but it also has like a layman's term. And I want to talk about the layman's term for a minute. There's this idea that if I punish someone, which is just I bring them pain and discomfort. They will not want to do that thing again because that pain and discomfort is so awful. And I think, like the sloppy, layperson's way of applying that is like, if I shame this child, if I yell at them, if I lecture them, if I embarrass them in front of the class, like that will make that will like dissuade them from doing that behavior again.
KC Davis 00:25:24 Right. And I think what I hear you saying is that one of the benefits to thinking about behavior analysis is to go, okay, but if you're not looking at the antecedent, if you're not looking at what's coming before this behavior, if you're not looking at ways that there are other like reinforcing factors happening in this behavior, then like you're not going to actually help that kid change their behavior or learn something different, right? Would you say that's accurate?
Lesley PsyD 00:25:57 Yes. Like, theoretically speaking, it should release us from the need to find blame inside of the child, because a core foundation of behavioral analysis and ABA is that all behavior makes sense. So it should help us remove that. And we'll get to the we'll get to the downsides of why that doesn't always happen.
KC Davis 00:26:20 Is it it does it. It almost seems like in theory that behavior is just this puzzle. Right. And if you figure out how to manipulate the what comes before, whether that's the environment or the emotion or the stressors or what somebody else is doing, and if you figure out exactly what to do afterwards to like, reinforce or not reinforce, you know, whatever, then you could change anything, right? Yes.
KC Davis 00:26:53 And certainly when we're talking about my kid running out into the road and really dangerous situations, like as a parent, like I want that the idea that there is a formula that if we just figured out the formula, we can stop that behavior from happening is very much something that, as a parent, I would want.
Lesley PsyD 00:27:10 Yes. And and for certain things, it's incredibly powerful. Like when I work with teachers, one of the most simple things that we talk about is I want this kid to speak up more in class. Great. What I want you to do is take some data this week on every time they make an attempt. And what happens right after. And many, many, many times teachers will come back and say they get sneered at. They'll try or they'll and they'll stutter or they'll say the wrong thing. And so we can talk about in that very simplistic scenario. What else would you expect that child to do? They behave a certain way. Something happens that causes an internal experience.
Lesley PsyD 00:27:49 They pull away and then they're safe. Of course, they're not going to speak up. So we can't keep expecting them to do something that's being punished in their environment. We have to create. So in that way, it's it's a very lovely formula and it can be very helpful as long as the behaviors are straightforward.
KC Davis 00:28:08 Okay, so that being said, let's move into what are the risks in thinking about everything in this way.
Lesley PsyD 00:28:17 So I think the biggest liability, with thinking from a very purely ABA lens is the oversimplification of behavior. And at this point, you know, I'm not shy when I talk about this field, that there was a reason I left this field. There's a reason that I no longer work in this field. That does not mean that there are not incredible ABA practitioners. I have several friends who, if I needed to, if I would, they would work with my kid in a second. But I have chosen to move away. And one of the one of the risks that we run is to oversimplify behavior down into just a simple ABC format and antecedent, a behavior and a consequence.
Lesley PsyD 00:28:54 When we do that, we can miss very important things like internal experiences, like histories of trauma, and we can run into a scenario where a slippery slope happens. And what we're reinforcing is actually compliance training. That is one of the risks is that we ABA can sometimes over develop compliant children rather than regulated children if applied in that way.
KC Davis 00:29:22 Yeah. It also occurs to me like, you know, there's a reason I chose those, like for behavior examples of like running into the street, like hitting yourself, not sitting down in school and eye contact. Right. Because it seems like one of the risks is like how you're even identifying the behaviors to target. Because one of the bigger criticisms about ABA is that for a very long time and and in much of ABA today, there was a lot of focus on things like eye contact and not stimming. Right? Like not doing hand flapping, things like that. And so people were applying this and everybody keep in mind we have not even gotten into the therapies.
KC Davis 00:30:07 So we don't know what ABA looks like yet. We just know about the thinking that we're applying to it. Right. So you go into, okay, this kid's not looking at people in the eyes. We want this kid to look at people in the eyes because that's what people do. And we want them to listen, right? Because how could you listen if you're not looking people in the eyes, and we want you to look more normal so that, you know, you can, you know, function in society. And so. Okay, well, why aren't they looking in the eyes and then like, what can we do to either reinforce someone looking in the eyes or like clinical term here punish or, you know, try to influence someone to not look in your eyes. Right. So it's it's not that you couldn't get the correct formula to force that kid to change that behavior, it's that the whole thinking process of why that behavior was chosen to be targeted. So can you tell us, like what? What is some of the fallout that has happened historically with ABA when it comes to what behaviors they choose to try and modify or change?
Lesley PsyD 00:31:09 So there's a strong history in, in ABA itself of encouraging behavior to move towards what we would call the neurotypical.
Lesley PsyD 00:31:19 So if it's typical for a 12 month old to be saying one word and to be able to hold eye contact for 20s and to be able to exchange a toy back and forth, then historically, Ava would take the child that is not doing that and view that as the goal. And we're going to move the behavior towards that, which for many children is not only inappropriate, it can actually set them back emotionally. Not all children can develop in that way. the suppression of stims is a is a major one that we've seen for many, many decades now that when ABA is applied to suppression of traits that are associated with autism, the long term emotional effects aren't great. We get more anxious kids, or we get overly compliant adults who then are not able to advocate for themselves, who are not able to say no. That would be another risk, I think, of using a pure ABA intervention. Is there is a risk there that what we are teaching children is that when the adults manipulate your environment, you follow the directions, period.
Lesley PsyD 00:32:28 And that is not helpful for a lot of our kids who struggle with self-advocacy and communication.
KC Davis 00:32:33 Yeah, because if you're, you know, if you're stimming because you feel anxious or because you're under stimulated or because you're overstimulated or because it's a self-soothing behavior or something like that, if you you absolutely could manipulate environments and reinforcements and punishments to get a kid to stop those behaviors. But if those behaviors were serving an important purpose and you don't like, give them any other way to serve that purpose, then it seems like you're making the internal experience of the child's distress even worse. And they're almost like learning, okay, stuff the discomfort and give the behavior.
Lesley PsyD 00:33:21 Yeah. And it can in certain circumstances, especially for children who are not verbally able, who don't have access to spoken language, it can create new behaviors that are much more serious, like self-injurious behavior, hitting self, biting self. And so we have to be so careful with a therapy or even just a thinking process that encourages us to manipulate the environment.
Lesley PsyD 00:33:46 We can do that. We do that to ourselves all the time. But when we're doing that as our primary way of changing things, we have almost taken the agency of that person out. So that is one of the risks that we have to be vigilant for when your child is in, in a therapy.
KC Davis 00:34:04 I remember learning from autistic adults about like their individual experiences with eye contact and and hearing stories like, you know, when I look at someone in the face, there are so many details in the face that I'm overwhelmed and I can't hear what they're saying. I remember hearing stories about them, about people saying like, it is physically painful for me to look at somebody in the eyes. And, you know, if you're a young child that can't verbalize that because even if you're a speaking child, like there's a level of introspection and language that that requires that you usually don't get till you're an adult to, like, put those things into words. Right. That is, is a little backwards, right?
Lesley PsyD 00:34:45 Yeah.
KC Davis 00:34:45 And we have this like emotional fallout. So well let's let's kind of summarize some of the, the benefits is taking the blame off of the child, trying to, you know, change environments that are best adapted to the child for them to make choices and learn things. And some of the risk factors or liabilities is oversimplified. First of all, the decision process on what behaviors are chosen. So choosing a behavior because it needs to look more normal, or choosing a behavior because like it's going to decrease distress for this kid or it's going to increase their quality of life. It's almost like the difference between choosing what will increase this child's experience versus like what will bring convenience to adults. What will make the what will make them easier to manage, will be less taxing or easier to manage in a in a classroom setting or whatever. So there's like the how we choose the behaviors. And then it also seems like there's a lot of risk in how you are sort of taking your data. Like, I remember reading a book about ABA and it was trying to say like, it's simple, you know, like when Susie goes outside and it rains, you know, she gets cold.
KC Davis 00:35:57 And then, you know, Susie learns that she needs to take a raincoat the next time she goes out. And if we look at the antecedents of of Susie being cold, right. And that like, went through. And I remember reading that and being like, it's not that that's necessarily a wrong way to think about it, but it's that you're missing a bunch of these antecedents here, like observable. You're going, well, if we wanted to teach. So it's like, okay, Susie goes out into the outside and it rains and she gets cold. And so she makes a choice to bring a raincoat next time. And so if we look at that and then we go, okay, so if we have a kid that we want to teach to choose the behavior of bringing a raincoat with us, all we have to do.
Lesley PsyD 00:36:49 Is.
KC Davis 00:36:49 Create a scenario that mimics the way a person might naturally learn this. So when Susie goes into this room without her, raincoat will turn the air conditioning down to 50 degrees where it's so cold, Susie will receive this reinforcement, reinforcing or dis enforcing information, and she will go and choose a, you know, raincoat.
KC Davis 00:37:19 And I remember reading that and thinking, but there there are so many variables that we just skipped over. Chief among them, the difference between rain falling from the sky and looking at a caregiver. Inflict discomfort upon you on purpose, like children can understand the difference And that is a completely different antecedent than rain.
Lesley PsyD 00:37:47 Yeah. And there's there's even more when when we get into talking about the actual therapy, there's even more than antecedents. There's setting events and there's language that functions as an antecedent, and there's so many complex behavioral phenomena that are happening. And the more contrived the scenario, the less applicable that will be to the outside world. And so one of the other risks, especially if your child is is attending ABBA center based activities, is what they're learning generalizable at all. So are they going to bring those skills out? So are we teaching them to be quiet, compliant participants in their class, or are we teaching them to self-regulate so they can engage in groups? That's very different. And so that when we talk more specifically, we'll talk about that.
Lesley PsyD 00:38:34 But that's one of the risk factors is there's a lot, unfortunately, that caregivers need to be vigilant for and aware of to know what quality of ABA their child is receiving.
KC Davis 00:38:43 So let's talk about the therapies for a minute, because the reason I bring up the raincoat example is because one of the things that I saw a lot in ABA are things like, okay, what is a possession this child really values? And let's bring it into the session and then let's ask them to do something and let's withhold that item until they do it. So whether it's we're learning colors today or we're learning to make eye contact today, or even something that might be a more quote unquote noble pursuit, we're learning how to not self injure today, or we're learning how to stay and hold a hand before we run across the street today. And so like, here's this thing you really want, and I will withhold it from you until you do the thing, and then you get the reward. Right. And that's that's why I think about, like, how different this contrived scenario where an adult withholding from you is a variable in and of itself that's not there with something like I learned that in order to watch TV, I must turn the TV on.
KC Davis 00:39:41 Right. Those are different variables. Then I learned that in order to watch TV, I must do this task that this adult has asked me to do. So talk to me about what the actual therapies looked like. Like, I know some of the terms, but I don't know what they mean. So like, I know the term discrete trial teaching. What is that? Yes.
Lesley PsyD 00:39:59 So ABA can take many formats. It can be in a group setting. It can be one on one with a therapist. It can be in a center. It can be with mom and dad, with the therapist at home and the I don't want to say older, but it is older. DTT discrete trial training is a way. It's actually a method of teaching. It's not specific to ABA and it's not specific to autistic individuals. It is a rapid presentation of these tasks to learn something new. And there's a lot of nuance and detail, but the way that we present things reinforce. And sometimes I don't think punishment is used as much, or response cost is another thing that can happen anymore.
Lesley PsyD 00:40:40 But in the past, and certainly when I started, there was a lot of rapid shaping of this learning behavior. And that occurs at a table. So it might look something like, look at me and there might be a visual prompt. And if they look great job. And then there would be some kind of reinforcement. So some sometimes it's something to eat, like an M&M, which again I think we've moved away from somewhat, but it's still in use. Or it could be a sticker or they could be earning stars for a break. And so it is a very DTT is incredibly contrived, but it's purposefully done so and that I think it's best utilized for skill acquisition. So for learning actual little skills, sometimes it's over applied.
KC Davis 00:41:20 So when I when I got diagnosed with dyslexia, one of the things that happened, like the summer after I got diagnosed was my parents took me to this center where for like a few hours a day, I would sit with a, I guess, a tutor, and I would do like workbooks, like phonics workbooks and writing workbooks.
KC Davis 00:41:37 And every time I finished one, I got a gold star. And then when I had a certain number of gold stars, like, I got to go to the prize box. Is that discrete trial teaching?
Lesley PsyD 00:41:48 So that would that is a phenomenon that is used in discrete trial training. But that's just reinforcement. So that is reinforcement which means you something happens and then something occurs after. And that makes the behavior more likely to occur. And once you've learned this symbology of like star five stars equals this thing I want, then you can hold that in your brain and the little sticker becomes reinforcing. But you have to be trained to get to that point.
KC Davis 00:42:16 So let me pause for just a second, because I don't want us to forget this question. I do want to talk about reinforcers and the benefits and risks of like you, because my understanding and you can correct me as like ABA is very heavy on reinforcers and I want to talk about benefits and liabilities of this idea of do it, get a star, do it, get a star like these kind of disconnected value ads, versus something that's a little more innate, like, you know, learn how to use a straw, get to drink something really delicious because, like, that's literally how you access the delicious drink or something.
KC Davis 00:42:50 Okay. So so what's what is it about discrete trial teaching that makes it unique? Then?
Lesley PsyD 00:42:56 It's unique because it is at a table. So it's table based and it's based on a skill. It's not very relational. It's not really focused on a lot of external environmentally appropriate skills. And if you ask somebody else, you may get a different answer than me. I'm kind of meta processing what I'm saying and hearing them say, yes, it is, but it's unique because it's a rapid style of teaching. It's at a table. And DTT is typically only used for new skill acquisition. So usually younger kids or adults with more significant disabilities and they need to acquire what are colors. Sometimes DTT is used to train safety signs so that there's this rapid recognition of what that means. The downside, I think, of DTT is that it's very difficult to generalize skills learned at a table to anything. So many kids and adults participating in DTT are going to effectively learn what they're being taught, they're going to learn it, but they're going to learn it at the table with that individual with this reinforcement system.
KC Davis 00:43:58 Is it like heavy on the flashcards? Because I feel like that's what I see where you'll have like a flashcard with a stop sign. And we're learning that the stop sign means to stop. But what we're doing is just like showing that card and having the kids say stop, and then they get like a cheerio, and then we show a different one and that one's go. And then they get a cheerio or like colors, like, what color is this? Tell me what color this is. Tell me what color this is.
Lesley PsyD 00:44:19 Yeah. And they can use the method of DTT. Can be used to then build skills. So at first we might start with put with same which is like match the color. And then we could use you know find the blue or we could have other distracting things there. So it can it's, it's an effective way to learn skills, to learn brief skills. You might see a lot of PT in speech. So it's not only in ABA therapy. You may see it in speech therapy and you may see it with speech sounds.
Lesley PsyD 00:44:47 So you may have a speech therapist saying, make your mouth look like mine. Oh, and then if they do it, great job and try again. It's a very rapid way of skill acquisition. It's not the only thing you would see in ABA. So ABA you would also see usually hopefully naturalistic skills too. So let's say if there is one of the challenges is the child is really afraid to join circle time. They are not doing it. In fact, they're running away. There might be something in the environment. And let's just use the example of again, using like stickers is assuming the sticker is reinforcing to the child where if they get close, they get a sticker, and then they'll get to have a break and come back. And then if they go and sit with their friends and they might shape their behavior in that way in an ABA session.
KC Davis 00:45:36 Okay. And so what is the benefit of like what does that help with. You said just like rapid like it's just more helpful because someone is like going over the same thing over and over and over with you.
KC Davis 00:45:49 Yes.
Lesley PsyD 00:45:51 This is a tough one for me to answer because the true, honest answer for me, the psychologist person, is, I think it's very useful for a very limited amount of things. DDT is most useful when we are talking about a very small skill that needs to be acquired before we can build to other things, but beyond that, it's so not naturalistic that it is not something. If I was referring a client, I would say use DTT minimally in your ABA sessions.
KC Davis 00:46:20 And then so that's like that's like the issue with the practice when it's done perfectly. Yeah. What are the issues that you see with the practice. Because it's rarely done perfectly.
Lesley PsyD 00:46:32 So I think the easiest way for me to explain this is again, the behavior analysis is this field of study. It's a scientific field and it has progressed way past basic ABA. There's things called relational frame theory, functional contextual ism. There's things ahead of where we were meaning.
KC Davis 00:46:51 That there's a better way of understanding behavior and how to change behavior.
Lesley PsyD 00:46:55 Oh yes.
KC Davis 00:46:56 Oh yeah. Like the the literal psychological science has advanced past everything we were talking about right now.
Lesley PsyD 00:47:03 Absolutely. But what happened is insurance companies latched on to ABA because it is an evidence based practice. It comes with data. So that's helpful for insurance companies. And they made it reimbursable. And it was really the first therapy that was kind of taken. It wasn't developed for autistic people. It was just a theory of science, but it was applied to autistic children. And because that happened, it has become a way to make a lot of money. And unfortunately, what we see happening, not in all ABA but in some, is that the bcba you might hear that term, those are the supervisors. Those folks have a master's degree or a doctorate. They are typically very educated. They've been doing this a long time. Are not the ones actually delivering the therapy. It is maybe bachelor's level folks, maybe master's level folks, but rarely who have received training. That is highly inconsistent depending on where you live.
Lesley PsyD 00:48:02 And so when you are taught the very basics of how to manipulate a child's environment, but you don't have all of the education and all of the other mental health education, you could end up just basically manipulating a child's environment for your own benefit.
KC Davis 00:48:19 Yeah. So we call them Bill Mills, where it's like the quality is it's not really about the quality. It's about like how many services can we get with people that we can pay? Not a lot so that we can reimburse a ton. And you know, you've also mentioned to me, you know, when I've asked questions about like, kids sitting at tables for hours on end and that it's just not developmentally appropriate. And I'll never forget listening to an autistic man on TikTok one time. And I wish I could remember who it was, but he was non-speaking as a child, but then was able to communicate through speaking as an adult. And one of the things he said was I hated ABBA because I was nine, ten, 11, 12, and they kept forcing me to do these elementary tasks pick the colors, pick the colors, pick the colors.
KC Davis 00:49:10 And I was bored out of my mind. And he said, it wasn't that I didn't know the colors, it was that I couldn't communicate to my limbs on where to put my hand at the right time. And there were other variables. I'm overstimulated. There's something else happening. There's something else that I'm experiencing. And I know what you're asking, and I know what the answer is. And I'm bored out of my fucking mind that you're asking me questions that you would ask a baby, but I can't make my body cooperate with what you're asking me to do. And I can't demonstrate my competence with this information. And that's like, seared into my memory.
Lesley PsyD 00:49:57 And unfortunately, a lot of times. And we can talk about well applied ABA as well. But poorly applied ABA often happens because the folks that are delivering the services again don't have the experience and background to understand all that nuance. And so they're also set up to fail. These aren't, you know, evil people. They're just don't have what you would need to truly understand.
Lesley PsyD 00:50:20 And so they're doing what they're supposed to do in their mind, and it's not working or it is working, but the child's not getting better. And that's when we see these very overly restrictive, overly simplified. So that would be one of the red flags to watch out for if you have your child in ABA, is that the team has a very simplistic, clear explanation for all of your child's behavior that seems like it should be a green flag. No child's behavior is that simple, and no one, no one knows all the things. That's just not how humans work.
KC Davis 00:50:51 So then talk to me about like, there's a couple other things that I've heard about ABA. Like they talk about like hand over hand and full body prompting. What are those things?
Lesley PsyD 00:51:00 So there are some things that we used to use quite a bit in this field that have not only fallen out of fashion, but, you know, legitimately, I really probably should not be utilizing one of those is edible reinforcement unless absolutely necessary, which is like giving kids food when they do something that we want them to do.
Lesley PsyD 00:51:18 Another one is hand over hand modeling or support, which is like I want them to touch the blue square, so I'm going to pick up their hand. Apologies for the motorcycle. I'm going to pick up their hand and physically touch the blue and then say, good job and reinforce that behavior. There's some gray area in there because there are kids with physical disabilities who perhaps need in an occupational therapy session, they they might need the hand over hand. So we're not talking about kids that need that. We're talking about kids who don't want to do it. Forcing a child's body to do anything and then giving a contrived reinforcement sticker or high five really has the potential to have very negative outcomes. They're losing the autonomy of their body and then being praised for giving that over.
KC Davis 00:52:07 Okay. What other things would we see like in an ABA therapy. Like that's always the hardest part for me is that there's a lot of discussion about it. But I always like, okay, what does that mean? What does it look like.
KC Davis 00:52:20 And then I kind of understand, like I understand what hand of a hand is. Now I understand about the reinforcements and I understand about the discrete trial teachings. And and let's talk about reinforcements for a minute, which is like what is the risk?
Lesley PsyD 00:52:36 There's a couple of big risks, and one of them is we have to be really clear that reinforcement is an idea. It's not a thing. So anything could be a reinforcer of of a rock, could be a reinforcer. If they did something I presented a rock and then they did that thing more often or more intensely. Then that rock is a reinforcer. The more contrived object that we tie to that behavior as reinforcement, the more difficulty that child is going to have. Doing it for any other reason. So if our goal is we're going to greet people and I'm just using this as a random example. So we're going to teach the skill of greeting people. But the only thing we ever reinforce that with is a sticker chart to earn a break.
Lesley PsyD 00:53:21 Then we may end up creating a very frantic child who says hi, hello, hi. Because we're just worried about getting to the break we want. Ideally, we want reinforcement to occur in the most naturalistic way possible. We we don't want to have to do an extra procedure to generalize this out into the real world and that, unfortunately, Sticker charts are notorious for that. Also, kids get bored of sticker charts, disabled or not, and so they often will satiate. And then when a child is bored and acting out, that's a brand new behavior we have to fix now.
KC Davis 00:53:53 So what is the difference between, like what happens in an ABA center or an ABA therapy session? And just like general classroom management in a first grade class, because sometimes it seems similar. And so it's hard when people are talking about like the, the risks and benefits and, and it seems like, well, okay, well, gosh, my neurotypical kid has a sticker chart in her kindergarten class. You know what? You know, I think a lot of times people will almost like deflect criticisms by being like, well, they do it in schools too.
KC Davis 00:54:26 And it's every time you give your kid a consequence, you're doing ABA, you know,
Lesley PsyD 00:54:31 So the biggest difference is that ABA is a purposeful thing that tracks data and has targets that everything that's occurring, ideally, everything that's occurring in an ABA center is all therapeutic. So it's not, in a classroom classroom is happening. And then we also have things like a sticker chart or fist bumps or a color chart. But those are like things that happen in the classroom. We're not necessarily the teacher is not taking data on whether your child's responding to that. In fact, that's why I hate sticker charts and, and clip charts and color charts and classrooms. And I wish we could get rid of all of them in an Ava center. That's all planned. So the interventions they're going to use are, are thought through in advance, ideally, and matched with your child rather than just part of their environment.
KC Davis 00:55:18 So is part of it just like the intensity level of some of these, like tech behavioral modification techniques?
Lesley PsyD 00:55:28 Yes.
Lesley PsyD 00:55:28 So it would be ABA is where everything that happens in the center is done for a reason specified by the team. Data is taken and the plan is adjusted. Everything is purposeful in a classroom. Those things may co-occur, but they're not. It's not for that purpose necessarily. The other thing.
KC Davis 00:55:48 Why is that? Why is that important? Because I can't put my finger on it. But something about that seems really significant, like it seems significant to be in an environment as a developing child Where I'm learning, I'm learning how to learn in other ways, or like I'm learning how to be. I'm learning how to exist. I'm learning how to relate in a way where I don't. Not every moment is this targeted emphasis of me trying to figure out what is expected next, or I don't know, am I on to something here?
Lesley PsyD 00:56:42 Yes. And and as always, I'll leave a little caveat in that. Every child is different. So these are generalizations. There are absolutely kids who benefit from being in an Eva Ava center and doing that very contrived work.
Lesley PsyD 00:56:56 There are kids who benefit. I don't want to dismiss or minimize the families that need that service. But in general, yeah, there's more. And that, again, that's one of the criticisms of ABA as it's applied today, is that it's this idea that doing everything in this way is better, but there are naturalistic learning opportunities for children. And also children's success is not always where learning happens, so sometimes doing things in the wrong way naturalistically results in learning too. And also, I think this expectation that all the kids are moving towards gaining competence in all these areas is not super realistic for anybody.
KC Davis 00:57:44 Yeah. Here's the last thing I want to ask, because when you said that, what I thought about is how like in a lot of like preschools, you know, you'll have like they're teaching kids how to color in the lines, but that's not developmentally appropriate. And there's a lot of really important learning on a neurological level, on a spatial visual level, on a like all these other even cognitive level that happens when a child colors without having to figure out how to put it in the lines.
KC Davis 00:58:15 Right? Yeah. which we just some of the stuff we just mess up about childhood in general, but also like, where does the influence of just ableism come in? Because sometimes I feel like things are expected of autistic children that aren't even expected of non-autistic children. Like my. My non-autistic child could not sit at a desk for that long. She could not drill colors like that. She could not color in the lines all the time.
Lesley PsyD 00:58:49 And I think that's one of the challenges also that I have with the language that ABA tends to use and not just them. We see this in other areas too sometimes in education is that things like, oh, Billy, he just he just shouts out all the time. He's so excited becomes for a child who is autistic with the same behavior, one of Billy's target behaviors is waiting on his turn to be called, where we tend to medical eyes and symptom wise things that are part of being a human being. and with Billy the fifth grader, the goal is not to eliminate all aberrant behavior.
Lesley PsyD 00:59:26 We don't talk about non-disabled kids that way, but sometimes in therapeutic settings, we do. As soon as someone is disabled, then we immediately talk about, well, how are we going to rid them of all their problem behaviors and fill in their skill gaps? And I think, I think it raises a lot of the humanity of our kids, and then it causes them to reach adulthood and have to try to rediscover that, they don't, you know, one of the criticisms, that a lot of autistic adults who become verbally able after being nonverbal for so long is that they speak robotically. And I think some of that is, is diagnostic. We can see that in some, people with autism. But a lot of folks gain that from therapy because they're taught to speak in this very rote, singsong way, and then they have to spend years undoing that. Yeah.
KC Davis 01:00:17 I will never forget to watch the young lady that I saw. She was like 18 or 19 making a video, and she was talking about how, like, she was going to therapy and she was trying to, like, I forgot what it was.
KC Davis 01:00:30 There was something she wanted to do that was like a self-care act. She wanted to either journal or she wanted to, like, utilize a planner. And she made this video where she was like, I had an epiphany. You know, I, I realized I can't make myself do anything when there's not a sticker, when there's nobody there to give this, like extra reinforcement. I like my motivation. Systems are broken. I never learned how to have, like, innate motivation in a way that mattered to me because I was just conditioned. And she's like crying on the video of like, I really now struggle as an adult because not enough people paid attention to other ways of learning that might have set me up better for long term success versus just sort of like short term behavioral modification.
Lesley PsyD 01:01:23 Yeah. And so people forget sometimes that these things that seem like they're naturally occurring to us, we most of us learned you have to be exposed to open ended learning opportunities that don't have a goal to develop internal motivation.
Lesley PsyD 01:01:37 That's that's part we need that it doesn't just happen overnight. And so it's one thing to say well this child's learning mechanisms are not functioning. So we're going to teach them this very specialized way so they can get the skill. But you can't then ignore opportunities for naturalistic exploration. And you know playing with playing making messes. Frankly, a lot of kids who get diagnosed with autism in their therapies, I've seen over the years, there's a huge emphasis on, like, always cleaning up, always being clean. Don't make a mess. And it's not what kids are meant to be anyway. and I so I think on a positive note, if you're looking for high quality services, if you're if you're saying to yourself, well, then what the heck, what would good, you know, good therapy look like, it's always going to be high and warmth and high and naturalism, it's going to be in kids natural environments using the toys that they already own or things in their environment. It's going to include their caregivers.
Lesley PsyD 01:02:34 It's going to include regular sounding voices, not something like this we don't like unless we're talking to very young children, which that's a normal speech tone. Yeah. and ABA can occur in those settings. It doesn't have to become to table point to same. It can be this other version.
KC Davis 01:02:52 Well, Leslie, this was very enlightening and very helpful. Do you know of any like, next steps for someone that's listening, that's a parent or maybe even an adult that went through ABA, or someone who is just trying to make sense of all of this, like where they could learn more or where they can read about it, something that is maybe a layperson's level.
Lesley PsyD 01:03:12 Yeah, I think a lot of that those connections are still at the local level and they are still on the good old Facebook. There are a lot of good Facebook groups looking for groups of former folks that have gone through ABA, or just looking for adults on the spectrum. Some folks can connect to larger organizations, but I will tell you that big organizations like Autism Speaks and some of the other ones are still not autistic led.
Lesley PsyD 01:03:36 And so a lot of times people will try to connect to those and not really vibe and not find people that have gone through what they've gone through. So typically starting I think very locally and usually on Facebook, maybe Instagram, I'm getting old, maybe that's old info.
KC Davis 01:03:52 Yeah. Okay. Well, thank you so much Leslie. Thank you.