Applied Behavior Analysis and Modern Autism CareApplied Behavior Analysis and Modern Autism Care

Modern care for autism spectrum disorder (ASD) has expanded beyond the paraprofessional delivered “gold standard” of applied behavioral analysis (ABA) over the past few years. It’s a move driven by several key factors: research demonstrating ABA is most effective with a subset of the ASD population, the breadth of ASD research that is driving clinical innovation, and the attitudes and preferences among people with ASD, their families and society as whole.

In this article, we take a look back at the history and impact of ABA in autism treatment, the shift toward new treatment options, and how the future of ASD therapy continues to evolve.

A Brief History of ABA

The foundation of ABA behaviorism was first studied in animals by B.F. Skinner and others and goes back decades. Skinner’s theory of operant conditioning was that learning and behavior change are the result of reinforcement and punishment. That means whatever happens right after the behavior may increase (reinforcement) that behavior or decrease (punish) that behavior.

ABA took off in the late 1980s with the publication of clinical psychologist O. Ivar Lovaas’ seminal 1987 paper showing the effectiveness of ABA treatment for people with ASD. Lovaas had been working with autistic children and ABA since the 1960s, publishing results that were considered groundbreaking.¹

The 1987 study reported that with an average of 40 hours a week of ABA, nine of 19 autistic children developed spoken language and that their IQs increased by an average of 30 points,² allowing them to be placed in regular classrooms. In 1993, he wrote a follow-up study reporting that eight of the nine maintained their gains and were “indistinguishable from their typically developing peers.”³ It is important to note that the criteria for the diagnosis of autism are not the same criteria we use today to diagnose ASD.

Around the same time, Let Me Hear Your Voice was published as autism was becoming a more common diagnosis. In the book, author Catherine Maurice described receiving her children’s devastating diagnoses of autism, struggling to find treatment and how with ABA, her children “fully recovered and are now considered ‘normal’.”⁴ Clinicians and understandably parents ignored the fact that 10 of the children in the Lovaas study made little progress even after receiving years of behavioral treatment after the study concluded. Desperate parents of children with autism began clamoring for ABA, quickly leading to its dominance as the gold standard in autism care.

Changing Expectations

The autism diagnosis is still relatively new. It was considered to be a part of childhood schizophrenia or psychosis until 1980, when the DSM-III recognized it as its own separate diagnosis. As such, it is a younger, not-as-well-understood condition.

Fast-forward to today, where ASD covers a wider-than-ever group of people under its 2013 updated definition in the DSM-5. With such a heterogenous population, one singular approach to treatment cannot be expected to successfully treat the myriad of people diagnosed.

ABA has become more controversial in recent years, and some research and meta-analyses have reached differing conclusions on how well it works for different aspects of ASD treatment. In a recent meta-analysis evaluating the evidence justifying the application of an ABA approach, Yu, et al. reported that outcomes of socialization, communication and expressive language are promising targets for ABA interventions. However, “significant effects for the outcomes related to general symptoms, receptive language, adaptive behavior, daily living skills, IQ, nonverbal IQ, restricted and repetitive behavior, motor skills and cognition were not observed.”⁵

Another meta-analysis published in 2022 found when studies with methodological bases were removed, only support for improved motor skills and daily living skills remained.⁶ On the other hand, another study found good support for using ABA to treat disruptive behavior, particularly when parents are trained to implement the behavioral intervention.⁷

Just as studies and analyses reached differing conclusions, other parent memoirs and books written since the publication of Let Me Hear Your Voice have shifted focus from getting to the “intact mind” buried inside every autistic child, regardless of severity, to learning to live with autism. In Chasing the Intact Mind, author Amy S.F. Lutz dives into the concept of the intact mind, its origins, and how it has influenced current policy and discussion around ASD and I/DDs.

Some in the autism community have become critical of ABA as abusive. Lovaas was controversial; many of his early experiments involved aversive stimuli for undesired behavior to punish a behavior and to add or remove stimuli to increase behavior (i.e., reinforce). Aversive procedures by caregivers as part of therapy remained common until the 1990s and included electric shocks.⁸

A Shifting Approach to Care

In recent years, it has started to become more accepted that high-hour, intensive ABA-as-the-gold-standard is not the sole approach to ASD care. More providers and payers accept that a hybrid approach, especially one that favors personalizing treatment to each individual and their unique circumstances and needs, is better for outcomes and can save on costs. Providers are increasingly asked about ABA and alternatives by skeptical parents whose expectations and preferences have shifted with the availability of quality information about their child’s condition and the proliferation of new treatment options such as naturalistic developmental behavior models (NDBI).

In other words, the current tools are not necessarily working for everyone. Given the fast-rising prevalence of ASD, it is time to evaluate how treatment is delivered, its effectiveness and cost, and develop care strategies that will leverage available intelligence, optimize outcomes, and reduce escalating costs.

Catalight has been at the forefront of this clinical innovation by providing families with the power of choice with new treatment options such as parent-mediated options (e.g., behavioral and developmental models), a 1:1 consultant model with the client and their licensed clinician, and parent training models where the parents would like additional support and training in how to parent their child effectively. And Catalight’s overarching philosophy to autism care is that each unique person should be treated with highly personalized care. That includes matching with well-suited care teams, developing individualized treatments according to needs and preferences, and coordinating care and case management to help ensure access to all available resources without lapses in care.

Catalight is dedicated to improving access, quality, and value at scale. With a network of more than 8,000 practitioners across a variety of disciplines, our solution meets clients’ needs while reducing costs for payers. Our results include industry-leading wait times of 4-7 days from referral to appointment and cost reductions of 30% in value-based contracting. We continue to innovate based on more than a decade of real-world clinical data and a mission to improve wellbeing for our clients and all their family members.

[1] Intense Therapy Shows Signs of Helping Autistic Children

[2] Behavioral treatment and normal educational and intellectual functioning in young autistic children

[3] Long-term outcome for children with autism who received early intensive behavioral treatment

[4] Maurice, Catherine. Let Me Hear Your Voice: A Family’s Triumph Over Autism. New York: Fawcett Columbine, 1994.

[5] Efficacy of Interventions Based on Applied Behavior Analysis for Autism Spectrum Disorder: A Meta-Analysis

[6] The Efficacy of Early Interventions for Children with Autism Spectrum Disorders: A Systematic Review and Meta-Analysis

[7] Efficacy of psychosocial interventions for Autism spectrum disorder: an umbrella review

[8] Divisions over ABA