Though ABA services have served as the primary support services for autistic people, the nature of its deliverance and the history of ABA has drawn criticisms from the autistic community, concerns which must not be disregarded under any circumstance. Thus, Mathur, Renz, and Tarbox (2024) suggested ABA practitioners adopt a client-centric approach in their practices to prioritize their input in delivering services. By doing so, practitioners could begin affirming neurodiversity while ensuring the concerns raised by the autistic community were addressed as often as possible. Additionally, the authors also ensured to use identity-first language throughout the article (“autistic” as opposed to “individual with autism”) to conform with the preference of self-advocates.

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The authors compared the medical and social models of disability and how they contrast each other when affirming neurodiversity. They argued that the medical model viewed disability as a deficit that needs correction, leading to stigmatization against autistic people. This promoted ableism, which was defined as discrimination in favour of those who are able-bodied or able-minded. The inequity, as a result, omitted disabled people from participating in the creation of their own support plans, and they were expected to conform to society without any changes to established societal norms. Conversely, the social model viewed disability as arising from societal barriers to acceptance of autistic traits and unequal treatment of autistic people, while also acknowledging the existence of impairment associated with it. This model challenged the medical model by positing that disability is a minority identity and emphasized the importance of including disabled people in decisions about disability research and support services.

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Mathur, Renz, and Tarbox (2024) defined neurodiversity as a perspective of viewing neurological differences as natural variations in human functioning. The concept found its roots in the social model of disability by drawing on lived experiences of the affected communities. From this view, the locus of many of the difficulties associated with autism is not within the individual but is likely situated and worsened by environments designed around neurotypical expectations.

In contrast to the traditional medical model, the neurodiversity paradigm promoted equality among all neurotypes. By adopting neurodiversity into practices, drawbacks of the medical model can be potentially avoided, thereby fostering an empathetic perspective for autistics without discussing their variations as pathologies. The authors then highlighted and elaborated on five key criticisms of ABA practices that autistic self-advocates raised and how a neurodivergent paradigm can be implemented to address them.

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Among the many criticisms, the erasure of autistic identity was first addressed by the authors. Critics of ABA, such as the Autistic Self-Advocacy Network, argued that practices have historically and continue to try and make autistic people align with the norms set by neurotypical individuals. They alluded to abusive practices such as autism conversion therapy and their continued prevalence to “normalize” autistic traits by masking them. Even goals deemed “socially significant” were often defined from a neurotypical perspective, potentially encouraging autistic people to suppress natural behaviours. Authors outlined personal accounts of autistic individuals who often experienced sensory overload, emotional distress, and believed autistic traits were unacceptable to societal norms. Studies associated this masking with several negative outcomes, including exhaustion, mental distress, burnout, and increased risk of suicidality. Although social benefits from masking were also reported, studies suggested that an accepting and supportive environment may reduce the perceived need to mask traits.

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In response to these concerns, the authors argued that practitioners should refrain from responding defensively to these criticisms and openly acknowledge the historically abusive practices. They condemned the idea of basing intervention plans on autistic traits mainly because they are different to neurotypical traits and proposed prioritizing quality of life, individual values, and autistic strengths. They suggested two ways in which masking of autistic traits can be addressed. First is by strictly evaluating whether repetitive behaviour, such as stimming, needed to be reduced in any capacity. Authors reported advocacies that argued stimming can help with regulation and maintain focus, with scarce research arguing otherwise. Additionally, suppressing traits that are part of an individual’s identity was severely unethical. Second, practitioners can help clients manage the effects of masking by educating them about autistic burnout, supporting unmasking in comfortable environments, spending time with accepting and supporting individuals, and separating from social demands.

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Criticism has also been raised of ABA practitioners’ over-reliance on compliance based procedures. Autistic adults have described experiences of being repeatedly coerced to comply despite distress, often resulting in emotional trauma. Authors reported that without regard for assent, forced compliance to participate in procedures was likely to lead to reduced self-advocacy, lowered self-esteem, anxiety, and vulnerability to abuse and assault, particularly over a prolonged period of time. Some advocates also pointed to preliminary research suggesting that autistic individuals who received ABA interventions during childhood reported increased rates of post-traumatic stress symptoms than those who did not receive the intervention.

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In response to these concerns, the authors recommended that ABA practitioners emphasize client assent and self-advocacy throughout treatment. Rather than relying on escape extinction and continued engagement with demands placed on the individual, practitioners ought to view avoidance or escape behaviours as the individual’s way of communicating their discomfort with the situation. When recipients of services retained control over their participation through established assent and assent withdrawal guidelines, they were more likely to continue engagement to gain the benefits of the procedure. The authors also noted that the primary ethical concern is not the use of rewards themselves but rather the manner in which items related to physical and emotional security, such as access to comforting people or objects, are withheld. Inappropriate use of contingency has often been reported in intervention programs and neurodiversity advocates have raised concerns over the harmful effects of withholding said reinforcers unduly.

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The article further proposed adopting a trauma-informed care (TIC) approach into ABA services. A TIC approach was likely to recognize the impact of trauma, ensure safety of the service recipient, maintain bilateral trust, promote client choice, and focus on skill development. By incorporating TIC into ABA practices through non-contingent disengagement, consideration of past trauma, and avoidance of interventions that could potentially lead to retraumatization, practitioners may help address concerns about ABA while supporting long-term mental health and well-being of service recipients.

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The field of ABA was also criticized for the lack of representation of autistic people in research, education, and organizations. The authors argued that inclusion of autistic voices was an ethical obligation for all researchers and practitioners as well as a necessary step toward improving services offered. They suggested that autistic voices should be made prominent across ABA research by involving autistic individuals to collaborate in research methodologies and as reviewers and advisors throughout the research process. Due to the historical prominence of ABA services as support for autistic individuals, their perspectives were likely to provide insight into the long-term effects of similarly planned interventions. Furthermore, increased representation of autistic voices in ABA graduate programs was also recommended in a variety of capacities. This included recruitment of autistic students, creating neurodiversity-affirming environments for learning, inviting autistic guest speakers, and incorporating autobiographical accounts from autistic authors and creators into the curriculum. Beyond education, ABA organizations were encouraged to review their goals and reconsider how their practices aligned with accepted neurodiversity principles. This could be assisted by creating a neurodiversity advisory board and hiring autistic consultants to implement changes that can make the organization more inclusive and neurodiversity-affirming. Appropriately selecting guest speakers and experts for such practices as well as sufficiently compensating them was emphasized to ensure avoidance of tokenism. Additionally, organizations were advised to take steps in order to ensure the needs of all autistic individuals were met as they may require support differently. This may also include revising what organizations meant by professionalism and appropriate behaviour.

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Lastly, neurodiversity advocates have also criticized ABA practitioners for pressuring parents into believing it is the only viable service option. Authors described personal accounts from parents who reported practitioners leveraged their fear and used other coercive means to convince them that ABA therapy was required for their children’s well-being. The treatments administered were deemed torturous and misaligned with the parents’ view of what is best for their child. The authors argue that ABA professionals have an ethical responsibility to provide families with unbiased and accurate information about the full range of interventions available so parents can make an informed decision. Although ABA-based interventions were once the primary support means for autistic individuals, other approaches such as the Early Start Denver Model and JASPER, have also demonstrated effectiveness. Further suggestions included parent training plans to be based on neurodiversity-affirming principles by helping families understand and appreciate their child’s unique strengths and perspective.

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Although the authors acknowledged that they do not represent every perspective and criticism within the neurodiversity community, the primary aim was to encourage practitioners to take steps in the direction of affirming neurodiversity. They identified prominent criticisms of ABA and argued that meaningful progress can only be made by addressing these concerns and actively listening and responding to the autistic community. By centering the voices of autistic people across the field, practices can be improved by drawing from their lived experiences. Authors deemed the acknowledgement of their trauma and perception of their disability from a social model, essential prior to implementing intervention plans. Given the abusive history of the field, it is understandable why members of the autistic community are likely to approach ABA with mistrust. Although these practices may not be as prevalent, it is important to acknowledge the longing damage the service recipients have endured. Ultimately, the authors concluded by stating that the shared goal of ABA practitioners and neurodiversity advocates was to improve the quality of life of those seeking services without requiring them to compromise their identity. The future of ABA will depend on how its practitioners and communicators respond to criticisms by autistic self-advocates. 

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Citation:-

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Mathur, S.K., Renz, E. & Tarbox, J. Affirming Neurodiversity within Applied Behavior Analysis. Behavior Analysis Practice 17, 471–485 (2024). https://doi.org/10.1007/s40617-024-00907-3