We have seen a number of comments on social media calling out organizations that provide ABA services to autistic individuals for recommending relatively high dosages of ABA services, typically defined as a fairly high number of hours of direct services per week. Often such comments state or imply that that practice is unethical. We suggest reconsidering that position, for several reasons we’ll outline here.
As a friendly reminder, multiple provisions in the Behavior Analyst Certification Board Ethics Code for Behavior Analysts obligate ABA practitioners to use and recommend services that are based on scientific evidence, and to educate consumers about that evidence so they can make informed decisions. For young children diagnosed with autism, the best available scientific evidence indicates that comprehensive ABA intervention for at least 30 hours per week produces substantially larger improvements in key domains than less intensive (i.e., lower “dosage”) ABA intervention, eclectic mixtures of interventions, and other early intervention services (e.g., see this “Clarifications” document published by the BACB and APBA). Some studies that are touted as showing that low-intensity ABA treatment is highly effective for young autistic children have serious methodological weaknesses. Some may have been influenced, funded, or conducted by entities that are financially incentivized to favor lower-intensity services.
It’s important to note that the young autistic participants in most of the sound studies of comprehensive, intensive ABA intervention published to date represented all levels of severity. That is, the evidence does not support recommending intensive intervention only for those who are deemed to have moderate, severe, or profound autism. That’s consistent with our profession’s standards of care, which call for services to be individualized to the needs and preferences of each client regardless of their diagnosis, chronological age, or functioning level.
In addition to the studies of early intensive ABA intervention for autism, many scores of peer-reviewed studies document the efficacy of focused ABA interventions for building useful skills and reducing dangerous behaviors in individuals with a variety of diagnoses. Some of those clients may require relatively intensive ABA intervention to help them acquire skills and reduce challenging behaviors in order to enhance their health, safety, and independent functioning. The point here is that dosages and other characteristics of ABA interventions should not be predicated on diagnoses or severity levels alone (see the Model Coverage Policy published by the ABA Coding Coalition).
Some argue that high-intensity interventions are too much for autistic children to handle, that high-intensity ABA consists mostly of discrete-trial drills, and that it’s wrong to teach young children to follow instructions, attend to tasks, and sit at tables. Those assertions are not borne out by the research on early intensive ABA intervention. Indeed, they contradict the evidence from that research as well as the facts that high-quality ABA intervention for autistic children has long comprised many procedures – structured as well as “naturalistic,” both learner- and practitioner-led — and emphasized making learning fun. There has also been an emphasis on building skills that will ultimately help learners succeed in home, community, educational, and work settings.
In sum, although we are not fans of arbitrary “red flags” for ABA service providers, we can’t help but wonder why those who are, advocate in favor of practices that are not supported by the best available scientific evidence, given the BACB Ethics Code.
Additionally, we suggest that instead of asserting or implying that all providers who recommend high-intensity ABA services for autistic individuals are unethical or “predatory,” it would be good to review the best available scientific research on the efficacy of various treatment models. No single study can produce definitive evidence, so it’s necessary to look to good systematic reviews or meta-analyses that synthesize and analyze results from multiple studies. Two examples in the realm of intensive, comprehensive ABA intervention for young children with autism are these meta-analyses of data on hundreds of individual participants in 16 studies:
Eldevik, S., Hastings, R. P., Hughes, J. C., Jahr, E., Eikeseth, S., & Cross, S. (2010). Using participant data to extend the evidence base for intensive behavioral intervention for children with autism. American Journal on Intellectual and Developmental Disabilities, 115, 381-405. doi:10.1352/1944-7558-115.5.381
Klintwall, L., Eldevik, S., & Eikeseth, S. (2015). Narrowing the gap: Effects of intervention on developmental trajectories in autism. Autism, 19, 53-63. doi:10.1177/1362361313510067.
There are also many reviews and meta-analyses of research on the efficacy of focused ABA interventions for several client populations. For some examples, see the bibliography in the ABA Coding Coalition’s Model Coverage Policy, cited earlier.
We support the notion that different service models are needed to meet the varied needs of autistic people, other client populations, and their families. Of course, further research is needed to refine existing models, and we hope entrepreneurs will work with researchers to develop and evaluate new ones.
Co-authors
Brandon Herscovitch and Gina Green
Partners Behavioral Health
_____
Partners Behavioral Health helps ABA clinic owners and operators structure a program based on best practice, and that meets the needs of their stakeholders and all applicable compliance standards.
