— Useful Links —
Music: Simple Gifts performed by Ted Yoder, used with permission
This client also has some echolalia and therefore, sometimes she could produce some really quite long sentences, but she had very little generative language. And she also didn’t have hardly any back and forth interaction. Well, her parents were told that language wasn’t a concern because she was putting three words together. When the mom asked the ABA therapist about her lack of interaction, her response was, “Well, we can work on that too.”
Hello, and welcome to episode 57 of The Speech Umbrella podcast. Get ready for a hot topic today. I have some thoughts about ABA therapy and I believe I can add something useful to that ongoing discussion. I noticed that the Asher Leader magazine has had some articles about ABA therapy and how speech language therapists and ABA therapists can work together and not tread on each other’s territory.
So this really is quite a controversial issue. Sometimes parents will ask me what ABA therapy is and what I think about it. This is usually after they’ve received a diagnosis of autism, because at least where I live, a diagnosis of autism often comes with the recommendation that they seek out ABA therapy. So when parents ask us about ABA therapy, how can we respond in a way that’s both professional and helpful, regardless of our personal feelings about ABA?
I think these questions I’ve come up with can help bring clarity to this issue.
I will ask parents will, what goals will the ABA therapist have and how will they go about meeting those goals? And I also ask them what background knowledge does the ABA therapist have in early childhood development, in sensory motor, play skills, and language development.
ABA is really a philosophy on how to treat speech and language disorders and a lot of other things too, actually, among the population of those with autism. So does your philosophy match the ABA philosophy? Let’s take a minute here and talk about what do I even mean by philosophy?
I don’t take the view that language is a behavior. I’ve had the most success treating clients on the autism spectrum when I really make a connection with them. The way I make a connection with these clients, with all my clients actually, is using mindfulness. And then I use my Hanen training on top of that for clients on the autism spectrum. It has made a huge difference in how effective I am.
I call my philosophy, a relationship based philosophy and a relationship based approach to treating children on the autism spectrum. And so it’s quite different from the ABA philosophy, which takes more of a behavior modification approach.
These are the points I want to cover today: What is ABA? In my personal experience, how have I seen ABA benefit clients? And some concerns I have around ABA.
Now, what is ABA? ABA stands for Applied Behavior Analysis. I’m quoting from the Autism Speaks website, which reads, “ABA therapy applies our understanding of how behavior works to real situations. The goal is to increase behaviors that are helpful and decrease behaviors that are harmful or affect learning. A qualified and trained. Behavior analyst designs and directly oversees the program. Treatment goals are written based on the age and ability of the person with ASD. Goals can include many different skill areas, such as communication and language, social skills, self care, play and leisure, motor skills, learning and academic skills.”
And for the reads, “The instruction plan breaks down each of these skills into small concrete steps. The therapist teaches each step one by one from simple, for example, imitating single sounds, to more complex, for example, carrying on a conversation.”
ABA therapy also uses what they call the ABC approach. It stands for Antecedent Behavior Consequence. And this is an example of how you would use that. This is again from the autism speaks website.
” The antecedent is the teacher says,” It’s time to clean up your toys at the end of the day.” The behavior is the student yells, “No.” The consequence is the teacher removes the toys and says, “Okay, toys are all done.”
And then they offer this alternative way to change his behavior. So the antecedent is still, the teacher says “Time to clean up.” The behavior is the student is reminded to ask, “Can I have five more minutes?” And the consequence is the teacher says, “Yes, you can have five more minutes.” And then with continued practice, the student will be able to replace the inappropriate behavior with one that is more helpful.
Now there is nothing wrong with the scenario. Although one could argue that any skilled teacher would be able to do this without being trained in ABA therapy. It’s a really simple example and I know ABA therapists are not always faced with such simple examples. Real life gets complicated really quickly.
While we’re talking about simple and complex examples, I want to share this quote with you by Oliver Wendell Holmes. He said, “I would not give a fig for the simplicity on this side of complexity. But I would give my life for the simplicity on the other site of complexity.”
So I think the real problem might be an oversimplified view of language. Is language more than behavior? Absolutely. Language development is a complex network of sensory, motor, play, cognitive, and executive function skills.
Given that language is so complex, would an ABA therapist know or explore why a behavior is happening beyond the antecedent trigger? Let’s take the example of having a child imitate a single sound, with the eventual goal of having the move to words, then conversation. If a child isn’t speaking and you want them to imitate a sound, do you understand why the child isn’t speaking? Do you understand the true antecedent? Does she lack phonation control? Does lack of breath control come from poor core strength? Is occupational therapy needed to build core strength, which can then lead to phonation control? And how will the ABA therapists determined which sound is most available to the child, given her current motor skills? So you see imitating a sound can be a lot more complex than just a behavior.
While we’re talking about imitation, let’s consider this. Imitation is really important. Sure. We all know that, but is it always something you would involve in your first step? My last podcast, which was an overview of the Hanen More Than Words program talked about children and what we call the “own agenda stage”.
A child in the own agenda stage doesn’t send direct messages to others. And in fact, that child will seem very uninterested in other people for much of the time. Would your first step with an own agenda child center on imitation? That’s something to think about.
Now I do want to bring up the point that I have seen clients benefit from ABA therapy. Here’s just some examples of that. I had a client once who was diagnosed with autism and she had absolutely no behavior issues, the sweetest little girl you could imagine.
So when her mom told me she’s going to get ABA therapy, my jaw hit the floor. And I said, “Why?” And her mom said “Toilet training.” She said “I have tried and tried and I just cannot do it.” And I totally understood why that child would need ABA therapy.
Here’s another example with another preschooler, by the way. He was about to go into kindergarten. He had made huge gains in his language. His parents recognized that he had some really significant behavior issues they wanted to address before he started kindergarten. So they decided to forgo private therapy in order to do ABA therapy. And I could really see the difficulties that they experienced in parenting. And I thought it was a good idea. I thought that this particular family could really benefit from the ABC, antecedent, behavior, consequence, method of parenting.
I’ve seen that ABA therapy can be beneficial when parents struggle with kids who have figured out how to manipulate their environment. They have figured out ways that specifically help them avoid doing the thing that they really need to do. They are avoiding the thing that can help them the most. And in those situations, ABA therapy can really help. Of course, it can also help in those situations where you need a really consistent methodical approach such as in toilet training.
However, what about when ABA therapy doesn’t match what the child needs? Here’s why I’m going to share some of the concerns I have based on specific experiences with clients.
One of my preschool clients was diagnosed with autism. She had no behavior issues. I had been seeing her a while before she got diagnosed and her parents and I had already discussed her sensory seeking needs and how occupational therapy could help her. And her parents already knew she was sensory seeking before they even came to me. They could see that.
When her mother asked the ABA therapist about occupational therapy, this therapist replied,””What good would that do?” I can only conclude that she didn’t see the sensory seeking or she didn’t think it was important.
I also conclude that she didn’t know or see that, although this client could run and climb like crazy, she couldn’t feed herself and she couldn’t figure out how to hold a hammer to tap a ball through a hole.
This same client also has some echolalia and therefore, sometimes she could produce some really quite long sentences, but she had very little generative language. And she also didn’t have hardly any back and forth interaction. Well, her parents were told that language wasn’t a concern because she was putting three words together. When the mom asked the ABA therapist about her lack of interaction. Her response was, “Well, we can work on that too.”
So then I asked, well, what did the ABA therapist first propose that they would work on for this little girl? And her parents told me that they said they could teach her to stop flapping her hands. Now, this was the least of her parents’ concerns. And in fact, it was rather offensive to her parents because one of them told me, I flap my hands when I get excited.
What’s really interesting about this child is any gross motor movement helped her talk. So walking, bouncing, running, flapping resulted in her being more vocal. So therefore, a goal to eliminate flapping her hands might even have been detrimental to her progress. Especially since her motor and sensory needs appeared to go unrecognized.
And who decided that hand flopping was harmful or detrimental to learning? What was the basis for that decision?
Another concern I have about ABA therapy is the amount of time required to implement it. Sometimes I’ll have parents call me wanting therapy for their preschoolers, but they want a really late afternoon time because their child has an ABA therapy for practically the whole day. And I can’t help thinking, okay, give the SLP the child when he’s worn out and already been through hours of therapy. Hm, what is wrong with this picture?
And why so many hours, I don’t know. Is it like a prescription? Is ABA methodology based on a certain number of hours required to get a certain result and are parents afraid of not meeting that number of hours? Or maybe money is part of the issue because some government programs fund ABA therapy.
This is something I don’t understand, but I think it’s interesting. The SLPs are only asking for an hour or maybe even only 30 minutes a week to do our intervention. Well, ABA therapy hours are so much more. Is this because what we do is powerful enough to be effective in smaller doses?
Finally, I’ve had some experiences with children who use AAC devices and ABA therapy. A lot of times the parents will come to me and say, well, they’ve been doing ABA therapy, but it isn’t really working. They don’t really understand how to use their device.
What we know about language applies to a child who is using an AAC device as much as it applies to any other child and you really need a deep knowledge of language and also there’s a lot of cognitive pieces that go into many children who are struggling to use an AAC device.
I had a conversation with a parent once who was looking at bringing her child to my clinic and I was asking her some really basic questions about his use of his device. And she said, I don’t know about that. I’ll have to ask his ABA therapist and I thought, Hmm. Okay, what is wrong with this picture? Does the ABA therapist know about aided language stimulation and how to implement it? I mean, even as SLPs, we don’t always know about aided language stimulation until we take some training on it or read a book about it. And by the way who is teaching the parent how to implement aided language stimulation?
A lot of parents have shared their experiences with me when they received the autism diagnosis and too many times they have told me, “All they told me was to get ABA therapy.” Some parents feel like they’re being sold ABA therapy because the clinic that did the diagnosing also provides ABA therapy. And other parents feel that they’re just being, given us one size fits all solution. I’m not saying that’s the intent of ABA therapy in its finest form. I’m saying that this is how it plays out in the real world.
That’s a boatload of concerns about this controversial topic, but this is my takeaway and it’s a two-part takeaway. First, in many cases, ABA therapy is too simplistic an answer for a child. To discover whether this is the case that you’re looking at this too simplistically, I go back to my original questions.
What goals will the ABA therapist have and how will they go about meeting those goals? What background knowledge does the therapist have an early childhood development, in sensory, motor, play skills and language development?
And secondly, ABA therapy is just one philosophical approach to treating difficulties that client’s experience who have autism. Approaches like Hanen and Floortime are relationship based and they’re on the opposite end of the spectrum from ABA therapy, philosophically speaking. Now that doesn’t mean that I don’t treat clients who are also receiving ABA therapy. It simply means that my approach will be different and I can explain this difference to parents. And it means I can explain my philosophy to them when they come to me and ask, “What about this ABA therapy they told me that I should get? What is it all about?”
I encourage parents to explore the philosophy around ABA therapy and see if it matches their own philosophy, in addition to asking those questions of the ABA therapist about their goals and their background knowledge.
I want to return to the simplicity and complexity that I talked about earlier. ABA seems a very simple, very direct solution to a lot of problems. I just remember that list I read off of all the things they can treat: the social skills, the language, the personal care, the motor, or the communication.
But perhaps that’s just the simplicity on this side of the complexity and it’s not really treating what needs to be treated. So we’ve got to go through the complexity and get to the simplicity on the other side. Because when you target the right simple steps. Yeah. The complex language really does start to take care of itself.
But knowing the correct first steps takes a lot of background knowledge in early childhood development, in addition to a deep knowledge of language development.
And that’s really why I do this podcast so that we can all develop a deeper, richer knowledge of language and how we can treat it.
Thanks for listening and talk to you next time.
I am a therapist and entrepreneur, clinic owner, published author, and creator of speech therapy materials.
The Speech Umbrella is run by Denise Stratton, Reach out with any questions.