Trigger warning: This post will discuss applied behavior analysis (ABA) and low expectations of autistic individuals and people with complex communication needs (CCN).
I stop at red lights. I avoid fast food. I wash my hands and use hand sanitizer…A LOT! I don’t do any of these things because I enjoy them. I would love to ignore traffic signals, but the consequence of doing that is that I could get a ticket or cause an accident. Fast food is unhealthy, causes weight gain, and it makes me feel a little sick if I do eat it. I wash my hands to avoid illness and also because I care about the health of other people. Natural consequences drive my behaviors, and there’s pretty sound science that explains it.
This is the science that is the foundation of the widely used, “industry standard” Applied Behavior Analysis (ABA) approach to teaching autistic children. This approach is often expanded to children who have complex communication needs (CCN) and are not on the autism spectrum.
There are three things I need to get out of the way before I continue. 1. I know that the science behind ABA is sound. This post is going to address the interpretation and clinical implementation of that science as it applies to communication. 2. I am not an ABA therapist. I am a speech-language pathologist and augmentative and alternative communication (AAC) consultant with 10 years of experience working in autism classrooms every single day. For two of those years, I worked exclusively in ABA classrooms with students in preschool, elementary school, and middle school. 3. If you are a Board Certified Behavior Analyst (BCBA) or ABA therapist and you’re awesome, it’s unlikely that you’ll be offended by this post. If you are offended, make sure that you are in fact awesome, and please let me know. There are several amazing behavior experts who have helped me to grow as a professional, and more importantly, changed students’ lives using their skills, compassion, and experience. Unfortunately, like any field, not everyone is awesome.
For anyone who is not familiar with these terms, ABA is the science devoted to the understanding and improvement of human behavior. Discrete Trial Training is an intervention that uses that science to teach and change behavior utilizing punishment and reinforcement. It is usually done one on one with an “ABA therapist” ( this can be an aide, BCBA, teacher, parent) and the student. Verbal Behavior Therapy (VBT) is used to teach communication using the principles of ABA. For the purposes of this post, I’m using the term “ABA therapist” to refer to the person who is working directly with a child and uses the science of behavior analysis in his/her therapeutic approach.
There are two issues that I see regularly during actual VBT sessions that are important to address because it is a waste of everyone’s time, at best. In the worst cases, VBT is actually harmful to communication, and more importantly, a child’s dignity.
ABA therapists are doing it wrong.
VBT is intended to align with the theories of B.F. Skinner and motivate the individual to learn language by connecting words with their meanings. It looks at functions of language and aims to systematically target those functions. The functions are: echoic (repeat a word), manding (requesting), tacting (labeling for the purpose of commenting i.e. “cat” when there’s a picture of a cat), and intraverbals (responding to a question i.e. “What’s your mom’s name?” student says, “Kathy”). It is supposed to be something that is interesting and reinforcing to the student and it’s supposed to be something that he actually wants. In the beginning, they are supposed to be reinforced for any type of communication (pointing, reaching, vocalization). The idea is to teach students that communication is rewarding and then use that to shape their communication into verbal words. Sounds completely logical, right?
Here is an example of what actually happens:
ABA therapist (holding a blue crayon): “Blue”
Student: reaches and says “buh”
ABA therapist (pulls crayon back): “Say it better. Blue”
Student: (visibly trying) “Buh”
ABA therapist: “No. BuhLUE”
Student: turns away, cries, crawls under the table
Here’s an example from a student who has an AAC device:
ABA therapist (holding up a piece of cookie): “Cookie”
Student: vocalizes “Eh” goes to device and says, “Cookie.”
ABA therapist: “No, say it. Cookie.”
Student: Uses device to say “cookie” and reaches for it.
ABA therapist: Pulls it back and says, “Cookie.”
Student: Goes to device, then slaps herself in the head and starts crying.
There’s a very important factor that often seems to be ignored in autism classrooms across the country, and possibly the world. The implementation of VBT is harmful to students who have CCN because many of these students also have apraxia. Apraxia of speech is a neurological motor speech disorder where the individual knows exactly what they want to say, but the brain has difficulty planning and coordinating the movements of the tongue, teeth, palate, lips and jaw to make that happen. Global apraxia extends this difficulty to movements of other body parts. For these children, they could be trying to “Touch apple” for years but their hands just won’t cooperate consistently enough for it to be “mastered.” Drill and repetition exercises and direct practice degrade the clarity of speech for children who have apraxia. This is crucial information if your child/client is in an ABA program because research shows that 64% of children initially diagnosed with autism were found to also have apraxia.
If your child is using a VBT to learn how to communicate, look at that program closely. I have looked back in children’s program books, and they have been working on the same verbal targets for years. If the goal of VBT is to have a child communicate using words, allow their AAC system to count. ABA programs who truly look at AAC as an extension of the child’s voice reinforce the use of that voice, with the knowledge that as soon as that child is able to verbalize those words, he will. If VBT is being used as a reason to prevent the child from using AAC because they are “working on verbal speech,” insist on providing AAC while you’re waiting for verbal speech to progress. Your child deserves to have communication and language regardless of his/her speech abilities.
We all need to be able to communicate to participate in life. People will communicate. If they don’t have a clear and consistent voice and an appropriate and effective way to use language, the only option is to use behavior. If a child is having sensory issues or his basic needs are not being met because he doesn’t have a way to tell anyone, he will express his needs through behavior. If you’re trying to teach a child social skills, he has to have a way to socialize that EVERYONE will understand to develop those skills. Communication is necessary to know if a child understands what’s been read or more importantly, his opinions about it. You get the idea.
The best Board Certified Behavior Analysts (BCBAs) I have collaborated with value communication above their ABA “programs.” They acknowledge that for children with complex communication needs (CCN), who do not have reliable, expressive communication, behavior is used to communicate. Communication is a priority. This brings me to the second point:
Communication is NOT a behavior.
VBT treats communication as a behavior. It’s just not that simple. Treating communication as if it is a behavior ignores the many dimensions and levels of language and communication. There is voice output (you could also say “speech,” but “voice output” generalizes it to include AAC). Speech/voice output that has shared meaning is language. When we try to describe communication, there are intricate levels of social referencing, gestures, eye gaze, tone of voice, word choices, and nonverbal elements that make it nearly infinite. Treating communication as if it’s a behavior is like comparing a middle school math problem to a Stephen Hawking chalkboard filled with complex equations explaining black holes.
Trying to fit language into a structured, data-driven format doesn’t allow for the creativity and spontaneity that occurs in natural language. Often, even when the ABA program allows a children to use their AAC system to respond, it becomes a negative interaction. “Errorless prompting” on an AAC device often turns into forcing a child to say what the ABA therapist wants them to say…over and over and over again. One way to tell if this is happening to the AAC users in your life is by looking for prompt dependence. If you say, “What do you want to do?” and a child relaxes his hand places it in your hand for you to move it wherever you want or grabs your hand so that you can guide him, he’s learned that someone taking his hand and moving it is how his AAC device is used. Not only is that kind of communication control detrimental to a child’s communication competence and independence, it’s dangerous.
What can we do instead to promote communication? Here is some good news for all of the lovers of evidence-based research: Aided language input (modeling) is an evidence-based AAC intervention. It is evidence-based for preschoolers on the autism spectrum in this study and this one. It is evidence-based for autistic students and adults with developmental disabilities and CCN. It is evidence-based for students with cerebral palsy. Just in case the AAC users in your life don’t fit into any of those groups, aided language input in itself is evidence-based practice, and you can read more about that here, here, and here. Model communication that is fun, interactive and reinforcing. Focus on connecting with the person in front of you. Be interesting and engaging.
In a data-driven system, spontaneity is uncomfortable for many, but as a field, we need to become comfortable with allowing children with CCN and especially children on the autism spectrum to be spontaneous. If a child using AAC doesn’t have the language to explore and experiment, she’s set up to fail. As a field, we need to accept that communication is not clear and easy to track, and that’s a beautiful thing. We need to look at our own behavior and make sure it aligns with a child’s basic human right to dignity and communication. And if it doesn’t, we need to make some changes.
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