As autistic physicians, we agree with the position of Dawson et al1: the neurodiversity movement regards autistic individuals to be both neurodivergent (diverging from the neurotypical majority) and disabled by environments not designed for autistic flourishing.1 Neurodiversity-informed therapeutic interventions therefore emphasize modification of external factors to better fit the autistic person.1 Therapeutic attempts to alter factors within the person must be done with utmost care to maintain the person’s autistic identity while helping support integration in the neurotypical world.1
Applied behavioral analysis (ABA) is a common intervention for autistic children. It seeks to modify socially significant behaviors in a measurable way.2 Operant conditioning theory is central to ABA, which views human behavior as intentional and contingent on interactions with the environment.2,3 ABA is delivered by board-certified behavior analysts, who use techniques such as modeling, shaping, reinforcement, and punishment to increase skills and so-called socially desired behaviors and reduce behaviors that are considered socially undesirable.2,3 ABA is foundational to other widespread behavioral interventions for autism, including positive behavior support.4,5
Surprisingly, board-certified behavior analyst certification competencies do not include demonstration of any clinical or theoretical knowledge of autism.3 Neither is neurodiversity considered.3 ABA therapy therefore lacks a genuine capability to determine what socially significant behaviors are for autistic people.1 Board-certified behavior analyst competencies do not provide guidance on how to preserve autistic autonomy in the delivery of behavior modification.3 Added concerns about ABA include lack of reporting of adverse outcomes,2,4 undisclosed conflicts of interest,4 and the use of punishments, including extreme practices such as aversive electric skin shocks.4
Although ABA has been shown to deliver modest positive effects, as in a recent umbrella review2 of autism intervention meta-analyses, the studies are of low or moderate quality. ABA and other behavioral interventions offered no measurable advantage compared to other nonpharmacological interventions for autism.2 With little clarity about which aspects of behavioral intervention might lead to positive effects, it was encouraging to see a recent high-profile recommendation to downscale the use of positive behavior support as an intervention for autistic people.5
As members of Autistic Doctors International, we hold a unique dual position as medical professionals and members of the autistic community. We believe therapeutic interventions for autism should be neurodiversity affirmative. We anticipate the rise of neurodiversity affirmative interventions with a fade to extinction for ethically questionable approaches that disregard neurodiversity.
Instead of behaviorism, “emphasize modification of external factors to “better fit” the autistic person…maintain the person’s autistic identity”. Consult these pages for more on neurodiversity affirming approaches.
2/4 We discuss our concerns about ABA, as doctors AND members of the autistic community
“…concerns about ABA include lack of reporting of adverse outcomes and the use of punishments including extreme practices such as aversive electric skin shocks”
We anticipate the rise of neurodiversity affirmative interventions with a fade to extinction for ethically questionable approaches that disregard neurodiversity.
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