ABA Therapy and other Therapies for Children with Autism

“We do that!  And we do that too!”.

ABA is the jack of all trades for Autism therapy. There are many forms of therapy under the ABA umbrella, including Discreet Trial Training (DTT; the traditional method), Functional Communication Training (FCT), Pivotal Response Training (PRT), the Early Start Denver Model (ESDM), Picture Exchange Communication System (PECS), Video Modeling, and more.  ABA continues to pull from a growing body of research and add strategies to their growing sleeve full of tricks.

But then why do some people say that they don’t recommend ABA?  What is so bad about it? Why does it help some people and not others? Also, if there are so many forms of ABA, what quality binds them all together?

Before I answer this question, I want to take a step back and share a metaphor I learned in a training program.

Every person views the world through tinted glasses.  Some see the world in a shade of blue and some in a shade of green, while others see purple or orange.  We can never see the world exactly as it is because we are human and we have feelings and biases.  We all have beliefs, and these beliefs shape our actions and our reactions to others.

ABA therapy, despite its ever-changing strategies and research, continues to look at Autism through a specific tinted lens.  ABA looks at Autism and sees a behavioral disorder.

Behavioral Disorder. Not a social-relational or co-regulatory disorder, but a typical reward/punishment behavioral disorder. This focus shapes the therapy and brands all of the subtypes with a distinct ABA flavor.  Some therapists do Discrete Trial Training at the table and some do ESDM or PRT on the floor. The focus continues to be behavioral.

The child does not want to sit at the table?  Shape their behavior by showing that you will not give in to tantrums and we will stay at the table.  The child does not want to look at pictures for 10 minutes?  Find a reinforcer (for instance, bubbles or M&Ms) to motivate that child’s behavior.  Even more, withhold that reinforcer all day to make it even more irresistible for the child.  The child makes loud noises and is not concentrating?  Cover their hands with yours and say ‘quiet hands’.  The child does not make requests?  Withhold the item until they realize that they must request in order to get the desired item. The child does not eat their vegetables?  Use first-then and explain that they must eat their vegetables if they want dessert. The child does not say ‘bye’ when you leave? Continue to prompt until they say ‘bye’.  Or, use pictures or sign language so that you can provide hand over hand assistance.

Let me break down the above examples through different colored lenses. I will assign ‘blue’ for behavior-focused ABA therapy and ‘green’ for a social-relational focused therapy with a mindful guiding thought process (Includes programs: RDI: Relationship Development Intervention, DIR Floortime, and SonRise).

The child does not want to sit at the table.

Blue: We need good reinforcers.  Let’s pair with the child and bring bubbles to the table.  If they still struggle, let’s consider different types of chairs. Perhaps it is not comfortable or does not offer enough support. We can do small sessions at the table, say 4 minutes, and we can set a timer so the child knows what is expected.  However, it must be under our control. My priority is to teach them to sit at the table so that they can attend to me.

*This is for the traditional model of ABA

Green:  What level is this child at in their interaction? What do they truly enjoy doing with their time?  Oh, this child never likes to sit, not even for meals?? Ah, they are an active child. My goal is interaction and teaching the child how to learn from me and enjoy my company. Let’s hold hands and run together, or spin, or crash into the couch.  I will increase the complexity of our interactions and focus on co-regulating or moving together.  We will focus on taking turns naturally and on making natural eye contact to learn information.  I will add challenges that are one step ahead from where the child is at so that they are always learning, but not pushed too far.   Ah, now the child is sitting on the floor all on their own.  I will help them sit in a distraction free environment (remove distractions, perhaps lay out a sheet for a visual highlight) so that we can concentrate on a lesson with each other.  Sitting at the table is important for meal times, however.  I will teach that food will remain at the table and try different chairs.  They are allowed to stand by the table if they prefer, but the plate will remain there. I can control the environment, but I cannot control the child.

The child does not want to look at pictures to learn vocabulary.

Blue: Reinforcers! They will learn that if they want the M&M, they have to give me the picture of ‘dog’ when I say “dog”.  I know this isn’t fun, but you want the M&Ms right?  And then after all of this ‘work’ (and in life we all have to work) we can take a break and play with water.

*This is primarily for the traditional model, but also occurs frequently in the more flexible ESDM or PRT.

GreenThey don’t like pictures, huh?  Wait, what’s the actual goal?? Ah, it is receptive identification so that they know that the word ‘dog’ refers to a dog.  First, are dogs important to them?  Do they have a pet dog or are we just checking this off a list?  Ok, so they do have a pet dog.  What’s the dog’s name?  Rover.  Do they understand when you say “Rover?”  This would be a more functional goal at this time.  What do they enjoy doing with Rover?  They like to give him treats?  Ok!  Let’s give treats to the child, hold the child’s hand if necessary (because kids with Autism need some support to maintain attention and proximity), and tell the child to find Rover!  Where is he…?  There he is!

This is a motivating activity that is also good for receptive language, and your child will feel proud and happy to help!  It is not as easy to measure true receptive accuracy because there are proximity and gestural cues, but children learn best in daily routines.

The use of reinforcers can shape behavior but finding a child’s motivation and imbedding goals into the motivating routines will create daily learning opportunities.

*These are examples, but if you have a professional who can personalize your program, you can find the ‘perfect fit goals’ for your child!

The child makes loud noises and is not concentrating; what do I do?

Blue:  Technically, punish the negative behavior and reinforce the positive behavior.  But, we don’t like the term ‘punish’, so let’s just gently give them the reminder “quiet hands’, ‘quiet mouth’, ‘catch a bubble’, or ‘no sillies’.  You would tell your typical child to be quiet, after all.  Then, we need to increase the reinforcers!  He is full of M&Ms and now it is no longer an exciting treat.  Hmm… let’s try using the tablet between trials. Or perhaps a few tickles to get him to change his concentration and stop stimming.

*All of the ABA subtypes.

GreenI need to learn more. That child is dysregulated because the child is either: overwhelmed, bored, momentarily distracted, or enjoying an independent reverie. I wonder which one it is? To find out, and help them re-connect, I need to STOP TALKING.  That’s right. Zip.  Let me just observe.

Maybe they are overwhelmed? 

Let’s just take a moment of calm and back down on the complexity of our activity.  I may introduce a regulatory pattern, such as pushing on the palms of their hand as I say “1”, “2”…  I can make my pushing weaker to invite them to push against me as well. This way we are working together and I am not doing all of the giving.  My goal for an overwhelmed child is that they eventually learn how to calm themselves down without my help.

Are they bored?

Maybe a change in activity is in order!

Momentarily distracted? 

I will continue our activity but pause as I hold one of their hands. We are stringing beads and I am holding the bead but it is their turn to pull the string.  I am not going to take their hand and help them (as Blue might), but I will hold one hand and wait. I may even say, “I am waiting for you to help me,” or, “I can’t do this alone!”.  I would not say, “Pull string” (as Blue might), because my goal is interaction and not behavioral output.  The child will soon realize that I am waiting for their turn and that our routine cannot be continued without their attention and support.

Momentarily enjoying their reverie?

If we are not in the middle of an important task, I can join them!  Oh, they are singing Frozen; we can sing it together! They are whistling or thinking of Thomas the train; let’s talk about it together! Even more basic, they are knocking on the wall.  Let’s knock together! If I get eye contact/interest from the child, then I can expand on the activity.

If we are in the middle of an important task where we each have our role, I will be patient and wait for them to regulate back to me. I will set my limits but I cannot control the child.

The child does not make requests.

Blue: The child needs to learn cause and effect.  First request, then receive.  They must learn that this is how the world works, and if everyone is on the same page then the child will comply.  We can support the child with pictures or signs, as it may be difficult for the child to speak.  Let’s pick the most reinforcing items and help the child request the target item. With practice, the child will be a wonderful requester!

Lets teach PECS:

First, let’s sit with the child.  We will start with one picture (does not need to be the correct picture.  Actually, it can be a blank piece of paper) and let’s hold a bag of M&Ms.  The child reaches for the bag of M&Ms but we don’t let them get it.  “What do you want?” we ask as we put out our hand.  We need another helper, and that helper provides hand over hand help to the child and prompts the child to put the piece of paper in our hand. “Good!” we say and give the M&M.  This is repeated 100s of times, until the child can give the paper on their own. Parents need to follow through and practice withholding items and encouraging their child to request ALL THE TIME. After the child can give the one picture, then they have to discriminate between 2 pictures and give us the correct one…

Once children can request (or mand), then we will teach them to make comments (tacts) such as, “I see M&Ms” or “that’s a dog”.  We will teach intra-verbals (1, 2… 3! Ready set… go!) and we will teach them how to answer questions (“What is this?  M&M.”  “What do you want?  M&M.”). Once the children know these 4 categories of language they will be able to have full conversations and make friends, right??

*All of the ABA subtypes

Green: Requests are difficult, especially since the child thinks that everyone knows what they want (children with autism are typically delayed in understanding theory of mind).

Let’s focus on a variety of expressive language goals and keep them functional! Pictures can be a good support; does this child already enjoy pictures?  Oh, they DO like looking at books and can recognize Thomas and friends.  They can most likely discriminate pictures that they are interested in!

Let’s put some pictures on the refrigerator. (Let’s start with ‘real’ pictures instead of drawings… depending on the child’s interests and ability). Let’s have the whole family (especially siblings) model that using pictures to request is fun and natural.  We don’t want the child with Autism to feel like they have to work harder or different than everyone else.  Let’s take the child to the fridge and ask, “What do you want?”  He tries to open the fridge but there is a lock on the fridge (setting the environment for success is important.  We want to teach that communication is essential to get needs met. However, it is only essential if the environment makes it essential. Locked doors and tall cabinets are our friends). We wait patiently and smile.  No rush.  The child may start to feel a little frustrated.  I want to help, so of course I will!  I move slow and steady, with some confusion.

I offer items he probably doesn’t want.  I take a picture off of the choice board, show the picture, and then present the food item. I am trying to be helpful, but I don’t know what he wants (or at least this is what I am teaching for now).  I will soon offer the food that the child wanted in the first place. (My best guess). The child sees the picture of the food I am holding with the real food beside it, and happily takes the food. Each time I may add more pauses and make more mistakes before getting to the correct food.  After a few times going through this journey to ‘figure out’ what the child wants, the child realizes how much faster (and easier!) it is to grab the picture of the food that is on the refrigerator.

I never withheld the item, I never started a power struggle, and I continued to focus on the reason to communicate in the first place.  The purpose is to share knowledge from one person to another. Communication is not a behavior but instead it is a sharing of mental information.

I am also going to highlight situations with comments.  I am not going to drone on about “Oh no the car is crashing! Oh it fell down. Look a blue car.  Look a red car…”, if the child is over 3 years old. Instead I will use dynamic and perspective-sharing language such as, “That car reminds me of the car we saw at Disney World!  I had such as fun time with you there.”

  • Check out my other blogs for more information on language enhancing strategies.

The child does not want to eat their vegetables.

Blue: All right, here is the oldest trick in the book! Let’s teach the child: “first eat your broccoli and then you get dessert”.  Adults must teach children ‘first-then’ concepts and the child will learn to comply.  Similarly with food, the child will learn to eat the vegetable if they really want their dessert. Parents must follow through on this approach. Nothing is worse than making a threat and not following through.  No broccoli = no dessert.  Of course, the goal is that if they try it enough times, they will one day love broccoli! One day…   However, if the child is VERY averse to foods, I will think about the textures and colors of the food and consult a feeding specialist for support. Perhaps we will follow the protocol of: touch the food, smell the food, bring it to the mouth, lick, bite…

Green“First eat your broccoli and then you get dessert…?” Hmm… if you say it like that, I bet the broccoli is pretty nasty.  I tell myself ‘first-then’ narratives when I wax my eyebrows; first I have to endure the pain, but then my eyebrows will look great. However, my goal in life is not to enjoy waxing my eyebrows, but it is to teach the child how to enjoy healthy foods so that they will lead a healthy life.  Given a situation where a child is hesitant to eat their vegetables, I am going try to be more observant.  Have I tried to cook vegetables in different ways? Is the temperature correct for the child’s liking?

I will also use ‘limit setting’ strategies instead of ‘controlling first-then strategies’.  My limit is that I will provide a variety of food options on the table, and the child can choose what they want to eat.  I will start with foods I believe will be successful and teach the child to expect the ‘rule’ of only eating what is on the table before I try to introduce meals that may have a chance of limited success.

I provide vegetables cooked in the right way, model healthy eating myself and discuss how much I enjoy it.  Here is the conversation I might have if the child does not want to eat their ‘real’ food and wants dessert instead.  I may say, “We can’t have dessert yet.  That is only served after everyone is done eating, and it looks like you are still working on finishing your dinner.  It is important that we at least taste all of our food! Take your time, and we can always re-heat, add more salt, etc.”.   The focus is on the routine (we have dessert when everyone is done eating) and not on the child’s behavior (first YOU eat the broccoli and then YOU get dessert).

If the child is extremely averse to trying the food, I may encourage the child to help me cook the vegetables. I want them to have positive experiences with healthy foods.

The child won’t say Hello or Goodbye.

Blue: This is easy.  Walk up to the child and say, ‘hello!’ or ‘good-bye!’ loudly in his face. If he doesn’t respond, prompt hand over hand for him to do a hi/bye gesture (wave, high five, shake).  At least you are teaching that a hello/good-bye routine must happen. It is even better if you can have an assistant provide the verbal cue, “say hello” or “say goodbye” so the child knows what to do.

Green:  I am happy to see this child, and I want to communicate that I am happy to see them. This is why we say ‘hello’ after all; to express that we are happy to share another person’s company.  When I walk in to see the child, are they busy? Ah, they are sitting on the floor playing with a car.  If I say, “hello” now, I don’t think they will answer.  They have not even noticed I am here.  Actually, thinking about it myself, I don’t like it when someone sneaks up on me and says ‘hello’ if I don’t see them coming.  I will sit with the child and gently hold one of their hands. When they look up at me, I will smile and say, “hello”.  Even if they don’t say hello back, that is ok for now.  When it is time to leave, I have more control over the routine (and ‘bye’ is easier developmentally).  I will take the child’s hand and walk with them to the door.  I may let the child open the door for me (if he likes opening doors. And if this will not cause a control battle for wanting to leave the house), and then I will get down to eye level with the child.  “Bye!” I will say, and hold up my hand in a wave or half-way ready for a high-five.  It is the child’s choice.  I will wait a long time (I am still holding one of the child’s hands, so it would be difficult for the child to move away suddenly), and I may even say, “I would love it if you could say bye with me. Let’s say it together, “bye!”.  I can also create a verbal routine around saying ‘bye’.  I may sing, “it is time for me to go… bye bye…” and wait for the child finish the last ‘bye’ in the song.  I will mention that it was a fun session with him, I will tell him when I will see him next, and then I leave.

I hope the above examples help demonstrate how two different ‘therapies’ can be similar in their goals, but because of the different colored lenses the actual focus is vastly different.

Isgreen necessarily better?  I cannot tell you what to think (and I apologize for the biases in this article).  I will say that every year I learn the importance of mindful decision making and have abandoned following a protocol just ‘because’.

I used to be an ABA therapist and I saw inblue‘.  I felt validated and dismissive at the same time. I felt defensive if someone had a differing view, and was quick to say, “I do that too”.

I no longer get defensive or push that “I am doing that to”.  Instead, I ask questions and try to gather more information… maybe we are doing the same thing or maybe we are doing something slightly different. I try to take every opportunity I can to learn from other professionals and parents without feeling defensive.

Conclussions:

But now what? What should you decide as the parent?  What therapies should you seek?

At the current time, ABA therapy is the most well-funded therapy out there for families and children on the spectrum.   If you choose to do ABA therapy, you will (likely) have the luxury of having your child handled by professionals all day long. Otherwise, you will get a few hours a week of other therapies, at best, and anything additional comes out of your own pocket.

ABA therapy is no longer as abusive as it once was. The history of its development is actually quite startling; this is why many adults with Autism are against ABA. The professionals working in ABA (like I used to) are well-meaning and awesome people.  They may have their own unique ideas and individual strategies, which is why you may hear of someone loving their ABA therapist. If you can get ABA covered and are VERY picky about who the therapist is, then it could be an asset.

However, I have never met an ABA therapist who sees in ‘Green’… at least, not at first. No matter how fun, or playful on the floor, or nice, the ABA therapist or BCBA was, they still viewed the child through ‘Blue‘ lenses. I have worked with over 100 different therapists from more than 12 different agencies, over 2 states, and all of the therapists see ‘Blue’.  I have been able to train a few ABA therapists (that I co-treated with) some of my ‘seeing in ‘green’ strategies, and the progress with the child was remarkable!!  If you find a well-meaning therapist, you may be able to help them make this small adjustment as well!

So, who seesGreen?

DIR Floortime:  Floortime has been increasing in popularity, which is great because it focuses more on the social-relational aspect than on the behavior.  But because it is a wide-reaching program with therapists of all different levels of training who claim to ‘do Floortime’, it is difficult to promise what the quality of the therapy will be.  I have met floortime therapists who see in ‘Blue’ and some who see in ‘green’.

SonRise: They ALL see in ‘green’.  This is a parent-focused program, meaning they teach YOU and not the child.  I would highly recommend the Sonrise books, and if you have the time and money to go to the training, it is a great jump-start to seeing in ‘green’!  However, there are aspects of their program that I no longer recommend. They put a lot of stress on the parents to always follow and join the child, and spend all day one on one with the child. For many families, this just is not possible. They don’t help families overcome everyday challenges and trainings are in 1-week intensive spurts with the parents, so you are constantly left wondering if you are ‘doing it right’.

-RDI; Relationship Development Intervention: This is the program I would most recommend. It is also parent-focused, and is similar to having a specially-trained Psychologist/Autism Therapist meeting with you to help improve your life and your connection with your child. You will learn how to interact with your child and how to repair the parent-child relationship. It is ongoing (instead of just one week like Sonrise), and it is affordable (since you are only paying for an hour of therapy every other week.) Additionally, since it is parent and coaching focused, it is up to you to find time to help your child and enroll them in schools and programs.  RDI can be done in combination with Floortime or with an ABA therapist who is flexible and willing to see your child with a relationship-building and guiding focus.