ABA Revisited

Autism is a challenging – and more and more frequently diagnosed – condition. In fact, as of 2018, the CDC estimates its prevalence as 1 in 44 children. While we might think of a child with autism as being non-verbal and exhibiting hand flapping and other odd behaviors, he could also look like any other child yet be struggling with many life skills. Children diagnosed with autism spectrum disorder, or ASD, differ widely. What they have in common are deficits in communication and social interaction, and 2) restricted, repetitive behaviors, interests, or activities.

Parents who learn that their child has autism are faced with a myriad of treatment choices. Dolphin therapy? Floor therapy? Sunrise therapy? Or plain old ABA (applied behavior analysis) therapy? The decision is truly daunting, but it is precisely this decision that will make all the difference in an autistic child’s progress. While new treatments abound, and some of them gain popularity on Facebook parenting groups, there is just one therapy that is highly tested and considered the most effective autism treatment. Unfortunately, it has somehow gotten a bad name lately – mostly in the frum community – a point that deserves study. That system of treatment is ABA: applied behavioral analysis.

What Is ABA?

Applied behavior analysis is a type of behavioral therapy that teaches skills and expected behavior by using reinforcement. In the past, it also used punishment. Perhaps that is why, when some of us hear the term ABA, we think of electric shock treatment and repetitive practice for reward, like Pavlovian dogs. And we cringe. Let’s revisit the 70-year history of ABA and hear the honest reflections of a leader in the field today, Dr. Ronit Molko, Ph.D, BCBA-D:

“To understand the evolution of ABA,” says Dr. Molko, “one needs to understand the history. It is based on the behaviorist psychology of Skinner and others in the early 20^th century, and by the 1960s, the application of ABA was rigid and unnatural. Children were required to sit through multiple, repetitive drills to learn skills and sequences, and the number of hours of intervention were exhausting. The popularization of Skinner’s methodology created a mindset among some parents and providers that intervention must be highly structured, rigid, adult-driven, and sometimes, aversive, meaning treatment could involve unpleasant techniques to alter maladaptive behavior.

“ABA has evolved into a much more naturalistic, engaging, play-based, and child-directed form of intervention,” says Dr. Molko. “In natural environment teaching (NET), for instance, treatment takes place within the ordinary routines of daily living, occurring during mealtimes, playtime, bath time, community outings (like a trip to the grocery store), and other natural parts of a child’s day. This sort of real-life teaching differs extensively from the overly formal, clinical settings of the past.”

Furthermore, Dr. Molko adds, the market for autism treatment has grown exponentially, which has unfortunately led to misusing the label of ABA for treatments that “do not meet the standards and definitions of ABA.” In other words, giving ABA a bad name may not be in reference to ABA at all.

Dr. Molko concludes, “It’s up to us, as a profession, to honor and respect each client’s and family’s wishes and values, and to discuss issues related to things like dignity, individuality, and self-expression. It’s up to us to honor selfhood.”[1]

Blue Balloon

Clearly, these thoughts do not sound like the words of an uncaring, regimented clinician. Now let’s peek in at a major early intervention center in Owings Mills, Blue Balloon.

In the morning I spent touring and interviewing Mrs. Miriam Newmark, BCBA, clinical director, I did not see one candy offered as a reward. Mrs. Newmark explained, as per Dr. Molko’s brief history above, that rigidly drilling children and rewarding them with candies is the old ABA. Her center uses natural rewards, such as praise and, for very young children, hugs and kisses – which I repeatedly witnessed. “The key to success is to connect with the child and earn his trust,” says Mrs. Newmark. “The first part of a treatment plan, therefore, is to pair oneself with the child through positive reinforcement so that the child looks forward to working with the therapist.”

Parents attend an evening or early morning ABA session with their child once a week so that they can carry over the same approach at home. Additionally, there is no such thing as punishment. In terms of respecting the culture of each family, Mrs. Newmark directs her staff to “determine individually effective treatment per child with the goal of becoming more independent than before.” In this light, only socially valid behaviors, not the therapist’s beliefs, are addressed. Furthermore, the emphasis on repetition has vanished as the directive is now to “mix and vary tasks all the time.”

This approach is not unique to Blue Balloon. The other centers in our community as well as the many centers in the tri-state area are all up to date. The majority of Blue Balloon’s clients are from the wider Baltimore area, and although it does serve local frum schools as well as families through home-based therapy, some of us in the frum community may not have realized the benefits of the modified ABA of the 21^st century. The rare account of incompetence has gained credence among us through the social media we have learned to trust more than our doctors or degree-granting institutions.

Essential Information

Parents of newly diagnosed children find themselves lost in a vortex of powerful emotions, facing an uncertain future and a formidable learning curve. One very helpful resource is the website of the Association for Science in Autism Treatment, asatonline.org, which contains a goldmine of information and contacts.[2] Parents will benefit greatly from searching a link here in which hundreds of therapies are researched and listed according to three categories: 1) studied and found ineffective, 2) studied and found effective, and 3) insufficiently studied, therefore lacking any conclusive evidence.

For instance, Floor Time, a therapy the frum community is excited about as the future of autism therapy, is found in the category of insufficient evidence. Insurance will not cover this or other therapies unless research has shown that the progress lasts. For this reason, ABA centers submit regular and detailed paperwork to such companies to document their treatment’s effectiveness. Among public school systems, physicians, insurance companies, and researchers, ABA is considered the gold standard of treatment for autism.  

A key factor in how present-day ABA maintains such high standards is found in its training. An MA in ABA is required, which includes 2,000 hours of supervision and a licensing exam to become a supervisor. Those studying for this goal are termed RBT, or registered behavior technicians, and work under a supervisor.

The goal of this article is to encourage parents who are perplexed by the many purported therapies for autism to turn to your doctor or peruse asatonline.org to find the professional who will help you. Visit an ABA center to see for yourself. We hear so much about the dangers of smartphones and social media. I sadly venture to say that this also includes the baseless distrust of the “world out there” that brings us to choose a therapy for our precious children from a post on a Facebook group.