They repeat like a mantra:
“ABA is evidence-based.”
“ABA is evidence-based.”
“ABA is evidence-based.”
Is ABA evidence-based? Can you explain why it’s “evidence-based”?
I am usually sent a list from a search for the word ABA in some academic study repository or a link to the ABA definition of Autism $peaks, which does not explain it either.
Do you think that allows you to qualify a practice as “evidence-based”? ?.
If you are going to talk about “evidence-based” interventions and practices, you should be concerned about what the phrase “Evidence-Based Practice” (EBP) means.
As defined by the Institute of Medicine (2001, page 147), USA:
“Evidence-based practice is the integration of the best research evidence with the clinical experience and values of the patient.
It must meet these three requirements:
-Client/patient perspectives and values
-Best current evidence
I will explain why I do not consider ABA to be an “evidence-based practice” according to each point:
1) Client/patient perspectives and values
Many “autism therapies” either lack patient perspectives or take the family as a client.
This makes the situation similar to when you decide to train a dog to walk on two legs all the time. Is it good for the dog? No. But maybe some family or trainer will insist on it because “it looks so funny” or “it’s convenient for the humans around,” without thinking about the dog’s well-being.
Luckily for dogs, dog training has codes of ethics that seek to avoid this in some countries. A luck that apparently people who receive ABA interventions does not have (1).
If the autistic perspective is not taken into account, it is very easy to fall into important biases (2). That’s why it’s doubtful that ABA complies with taking into account customer perspectives. And what should definitely NOT be defined as taking into account “client perspectives” is that a person’s tastes, preferences and precious objects are used to obtain obedience or compliance. The latter I consider abuse.
I also find it interesting that the definition of Evidence-Based Practice for Psychology, as defined by the APA (American Psychological Association) (3), includes the patient’s culture. This is important because there are many ABA practitioners who are unaware of the existence of an Autistic Culture and others who, although they know it, decide to reject or dismiss it.
2) Clinical Experience
Historically, the ABA approach has aimed to “normalise” the autistic person, or as Ivar Lovaas stated, to make us “indistinguishable from peers” (4).
The basic instances of training as ABA behavior analysts are the RBTs and the BCBAs.
I recognise that more and more BCBAs and RBTs take into account that stims are tools of self-regulation, that there are different sensory sensitivities, that difficulties in executive function are not a motivational issue, or that speech difficulties tend to have their origin in motor difficulties, etc. They learn this mainly out of an interest in their own personal or professional growth, usually by contacting the autistic community. It is not part of their training and is not for the moment the generality but the exception among ABA analysts and ABA behavior technicians.
-RBT©, which corresponds to Registered Behavior Technicians, have a bachelor’s degree, a 40-hour course, a background check, a competency assessment and another assessment. These are the people who, in most cases, will administer ABA in the centers, under the supervision of a BCBA.
-BCBA©, which corresponds to a Board Certified Behavior Analyst, requires training at the master’s level in Behavior Analysis, Education or Psychology. These trainings do not necessarily include training in autism.
Among ABA practitioners not even those who have a degree in psychology usually see more than two subjects in autism. It is often only one subject or even part of a subject and sometimes with DSM IV (outdated) as content or worse (5). In Behavioral Analysis careers, autism is usually an elective that I imagine is taught from a behavioral perspective and not from updated neuroscientific knowledge. In the area of education I have not seen autism in their curricula and my experience is that few educators know about autism.
I deduce that it may be because of the above, that studies on the effectiveness of ABA interventions even today include the elimination of non-harmful stims (or that are defined as harmful from subjective perspectives that do not take autistic traits into account) or an attempt to modify behaviors that are no more than a reflection of the discomfort felt when the environment is sensory, mentally, or emotionally overwhelming. (6)
3) Best current evidence
Even some behavioral analysts claim that standard definitions of “evidence-based practice” are not used on ABA and/or have replaced them with their own definitions (7). This is partly because most of the studies on which they rely to say that ABA is evidence-based are with experimental designs of few participants or often SINGLE SUBJECT!
This means that there are hundreds or perhaps even thousands of studies evaluating the effectiveness of ABA as:
-With the right reinforcement a person who did x will stop doing x, or a person who did not do z will do z.
But these studies do not evaluate or include an analysis of:
- The fact of whether x or z generates well-being in the person.
- If the process with which the person was able to stop doing x or achieve z causes damage or even trauma in the short, medium or long term.
- If with other methods, or by simple maturity or natural evolution, the person would still have learned to stop doing x or learn to do z.
To this we must add a few more aspects:
- That ABA studies do not usually include Randomized Control Trials (RCT). This is partly because of an ethical dilemma; those who advocate for ABA say they don’t consider it ethical to deprive autistic people of early intervention that has evidence that it “works,” (8) while those who oppose ABA don’t consider it ethical to expose autistic people to a therapy that in so many cases has caused harm and even PTSD.
- That the evidence in favor of ABA at meta-analysis level, in databases such as Cochrane, is overwhelmingly poor and is considered low or very low (9).
Therefore, according to the pyramid of evidence described later on, ABA stagnates in the middle part of this pyramid of quality scientific evidence.
HLWIKI Canada created this pyramid whose objective is, according to Students 4 Best Medicine:
“The Evidence-Based Medicine Pyramid is simply a diagram that was created to help us understand how to weigh different levels of evidence in order to make health-related decisions. It helps us put the results of each study design into perspective, based on the relative strengths and weaknesses of each design.”
For an evidence to be considered strong, it must be in the pyramid even above the RCTs and ideally supported by meta-analysis reviews such as those of Cochrane Collaboration who, according to Students 4 Best Medicine:
” takes systematic reviews to the next level. They are the experts of the systematic review and have an added a level of rigor as an independent voice, as well as developing special techniques to identify bias in studies”
We must take into account other biases such as funding and who benefits financially from the studies. The vast majority of ABA studies are funded and published by ABA’s own providers, which is undoubtedly a multi-million dollar business.
I want to think that all of us who are part of the debate about ABA as an intervention for autism want to do what we consider best and most responsible to improve the quality of life for autistic people. And the most responsible thing is usually believed to be what is evidence-based. When someone questions if ABA is an evidence based practice I ask to go beyond the claims of the providers themselves. Let’s go further, let’s question, investigate, look at autistic experiences. Let’s take into account the different perspectives and, if we are really interested in scientific evidence and not an automatic response, let’s demand the evidence to be strong, with fewer and fewer biases, that the medium and long-term effects are included, and also that it evaluates its benefits with criteria beyond behavior.
Edited to add links:
White background with a pyramid with two horizontal cuts.
At the top of this pyramid there are three levels. The upper one is pink and the text “Systematic Review”, the middle one is yellow and the text “Critically-Appraised Topics (Evidence synthesis and guidelines)”, the lower one is very light green and the text “Critically-Appraised Individual Articles (Article synopsis)”. To the right of this pyramid cut pointing from base to top and a box with the text “Filtered Information”.
In the middle cut there are three levels. At the top, lilac, “Randomized Controlled Trials (RCTS)”. In the middle, fuchsia, the text “Cohort Studies”. On the bottom, a toasted yellow color, the text “Case controlled studies – Case series / reports”. On the right side of this pyramid cut pointing from the base to the top cut and a box with the text “Unfiltered Information”.
In the lower court, the base, a single level, in bright green, with the text “Background Information / Expert Opinion”.]