Over the past five years, the Department of Defense (DoD) has spent over $1.53Billion on ABA services, serving almost 16,000 individuals with ASD.  The average cost per participant in FY2019 was $23,253.  In 2016 Congress authorized funding for a report to examine whether the ABA services they have been paying are effective.  Like all military health insurance services, these services are administered through TRICARE Insurance, health care program for United States uniformed service members, retirees, and their families around the world.

With 3,794 participants, this is the largest study ever conducted of ABA effectiveness.  The 31-page report entitled, “The Department of Defense Comprehensive Autism Care Demonstration Annual Report 2020” concluded that ABA services are not working.”

Specifically, they state (page 24 of the report):

“… these findings demonstrate that … the delivery of ABA services, is not working for most TRICARE beneficiaries in the ACD.”
“ … the Department remains very concerned about these results, and whether the current design of this demonstration, as well as ABA services specifically, is providing the most appropriate and/or effective services to our beneficiaries diagnosed with ASD.”

This was the second report prepared for Congress by the DoD reporting that ABA was not an effective therapy for individuals with autism. In last year’s report of over 709 individuals with autism, 76% showed no improvement after one year of treatment, 16% had improved, but that 9% were worse after a year of treatment.  For both studies, results are based on the  Pervasive Developmental Disorder Behavior Inventory (PDDBI; Cohen & Sudhalter, 2005). The PDDBI is a rating scale completed by parents, every six months. 

In addition to the PDDBI, two other outcome measures were required as part of the Department of Defense Comprehensive Autism Care Demonstration: the Vineland Adaptive Behavior Scale – Third Edition (Vineland – 3) which is a measure of adaptive behavior functioning; and the the Social Responsiveness Scale, Second Edition (SRS-2) which is a measure of social impairment associated with ASD. (Data from these measures were not reported, as no participants had the necessary two years of baseline data required for these assessments.) 

Analysis-1:  Pre/Post changes in PDDBI scores over 18 months:
In this report, they looked at pre-post (no control group) changes in PDDBI scores after 18 months.  While they found small, but statistically significant gains in PDDBI scores, they concluded that though statistically significant, “it is unclear if any of the change is of clinical significance.” (page 19).  In other words, just because something was statistically significant, didn’t mean that the effect was meaningful.  Moreover, they pointed out that without a control group, it was not possible to attribute the gains to ABA, or maturation over time, because some of these kids were undergoing other treatments simultaneously.

Analysis-2:  Relationship of Number of hours of ABA services with PDDBI scores:
If ABA is causing the PDDBI scores to improve, then one would expect that the more hours of services, the higher the PDDBI score.  This was NOT the case; there was no correlation between hours of ABA service and improvement in PDDBI scores.  In fact, some of the subgroup analyses showed a negative relationship, i.e., the more ABA hours of service, the poorer the scores on the PDDBI.  “In other words, the number of hours rendered does not appear to impact outcomes.” (page 21).

Research Review – In addition to their own lack of evidence of the effectiveness of ABA, the researchers reviewed other medical studies. They report that:

Two well-respected medical literature review services, external to DHA, continue to find the evidence for ABA services (Intensive Behavior Intervention) for the diagnosis of ASD is weak….” (page 15)
“The research literature available regarding ABA services predominantly consists of single-case design studies which does not meet criteria for reliable evidence” under TRICARE standards.”  (page 16)

Conclusion:
Department of Defense Comprehensive Autism Care Demonstration is the only large-scale study ever conducted of ABA.  The only conclusion one can take away from this report is that ABA is not effective

Some might argue that this is only one study, compared to the many studies that support the effectiveness of ABA. Based on a count of studies, this might be true.  But in a proper meta-analysis, inclusion should be weighed by the number of participants in each study.  When weighed against this large-scale study, adding those single-case studies would be little more than rounding errors; their effect would not be merely negligible, they would be invisible.

This blog reported on the lack of evidence of the effectiveness of ABA. My previous blog (https://therapistndc.org/fundamental-research-problems-bcs-asd/), presented the case against the Board Certified Specialist in Autism Spectrum Disorders (BCS-ASD) that ASHA seems to be encouraging.  A later blog will report on research questioning the safety of ABA.  

ABOUT BARRY R. NATHAN, PhD
barry@concierge-pgh.org
(412) 901.2685

Barry R. Nathan, Ph.D., is the Advocacy Initiative Co-Chair for the Therapist Neurodiversity Collective. Barry is an organizational psychologist and founding director of Concierge Pittsburgh, a regional initiative to retain and attract African American professionals in Pittsburgh.  Barry’s wife, Janice Nathan, is a certified speech-language pathologist who specializes in helping autistic children and neurodivergent children.


10 Responses

  1. The Military should look at funding and researching much cheaper developmental and relationship based models such as DIR Floortime, Relationship Development Intervention (RDI) and PLAY Project that train the parents and have strong research for their clinical significance.

  2. My son has been in ABA therapy since 4 he is now 11. There has been progress in his behavior and started as severe and is now considered moderate. He is considered high functioning. I often wonder if he would have still made progress without ABA. In school is interacting with other children on the spectrum and at times I feel this may actually be a hinderance to normal development. When I was interviewed by a psychologist he stated that I was defensive and tried to appear competent and “unstressed.” I believe psychology to be a pseudoscience, which is what he may have detected. Also as a Christian I actually am not stressed out. My son is doing well and I’m hopeful about his future but have doubts that the progress made is due to ABA.

    1. Dear Mike,
      Thank you for your comment. I have posted some resources for you below.
      Previous autistic recipients of ABA report trauma, anxiety, loss of identity, body autonomy violations, denial of self-determination, and personal agency. Some have reported suicidal ideation because they were taught that unless they mask any traits of autism they are deficient human beings. Training children to pretend they are not autistic by hiding it does not cure them. There is no cure for Autism. Autistic people should not be conditionally acceptable but loved for exactly who they are. We believe in therapies that help with communication, self-advocacy, and self-determination.

      The Autistic Self Advocacy Network has published a guide to ethical service delivery that may be helpful.
      https://autisticadvocacy.org/policy/briefs/intervention-ethics/

      Harmful Outcomes of ABA:
      Evidence of increased PTSD symptoms in autistics exposed to applied behavior analysis
      Kupferstein, H. (2018). Advances in Autism, Vol. 4 No. 1, pp. 19-29. https://doi.org/10.1108/AIA-08-2017-0016

      How much compliance is too much compliance: Is long-term ABA therapy abuse?
      Aileen Herlinda Sandoval-Norton & Gary Shkedy | Jacqueline Ann Rushby (Reviewing editor) (2019) How much compliance is too much compliance: Is long-term ABA therapy abuse?, Cogent Psychology, 6:1, DOI: 10.1080/23311908.2019.1641258

      Sandoval-Norton, A.H., Shkedy, G. & Shkedy, D. Long-term ABA Therapy Is Abusive: A Response to Gorycki, Ruppel, and Zane. Adv Neurodev Disord 5, 126–134 (2021). https://doi.org/10.1007/s41252-021-00201-1

      Ethical Concerns with Applied Behavior Analysis for Autism Spectrum “Disorder”
      Specifically, we will argue that employing ABA violates the principles of justice and nonmaleficence and, most critically, infringes on the autonomy of children and (when pushed aggressively) of parents as well.
      Wilkenfeld DA, McCarthy AM. Ethical Concerns with Applied Behavior Analysis for Autism Spectrum “Disorder”. Kennedy Inst Ethics J. 2020;30(1):31-69. doi:10.1353/ken.2020.0000

      Autism and Behaviorism – New Research Adds to an Already Compelling Case Against ABA, By Alfie Kohn
      https://www.alfiekohn.org/blogs/autism/

      Dawson M, Fletcher-Watson S. When autism researchers disregard harms: A commentary. Autism. 2022;26(2):564-566. doi:10.1177/13623613211031403

      The Double Empathy Problem:
      This is a fantastic introductory video overview about The Double Empathy Problem, presented by contemporary researchers who are researching The Double Empathy Problem. Dr. Noah Sasson is a researcher at UT Dallas.
      https://www.youtube.com/watch?v=TY1FBvJpzW8&ab_channel=DrBrett

      Layman’s Terms – Double Empathy: Why Autistic People Are Often Misunderstood – There are 9 research studies listed at the bottom of this article for further reading.
      https://kids.frontiersin.org/articles/10.3389/frym.2021.554875

      UT Dallas – Study Challenges Assumptions About Social Interaction Difficulties in Autism
      https://www.utdallas.edu/news/health-medicine/autism-social-interactions-2020/

      Diversity in Social Intelligence – The University of Edinburgh:
      https://dart.ed.ac.uk/research/nd-iq/

      Diversity in Social Intelligence: Methods, Results, and Implications.
      “Autistic people have just as good interactions with autistic people, as non-autistic people do (with non-autistic people). More information about the DART LAB’s research work into Diversity in Social Intelligence, as well as ongoing research in The Double Empathy Problem, and Autistic Masking.
      https://youtu.be/dEvg4tbiEhU

      http://dart.ed.ac.uk/wp-content/uploads/2019/04/Diversity-in-Social-Intelligence-Participant-Summary-.pdf

      https://www.youtube.com/watch?v=dEvg4tbiEhU&ab_channel=DARTLAB

      “We found that the chains of autistic people only and the chains of non-autistic people only were as good as each other to transfer information efficiently. This is a very important finding, as it means that when autistic people interact with other autistic people, they can interact with each other as well as non-autistic people interact with other non-autistic people. We also found that the chains that included both autistic and non-autistic people were not doing as well as the others to transfer information. This is again an important finding, as it suggests that the social difficulties experienced by autistic people are indeed greater when they interact with non-autistic people, who do not share their social understanding and culture.”
      https://patrickwildcentre.com/diversity-in-social-intelligence/

      1. I’ve been an RBT for almost three years and I have to agree that is field is abusive. I have not seen any progress in the children I have worked with and the ones that have been getting “services” long term are absolutely robotic. I hate it and am actively looking for a way out!

  3. I worked as an RBT, QASP, and now a BCBA. I own a learning academy but I practice alone, with no RBT. As a person who has several labels (diagnoses) I battle each day, I witnessed some really traumatic incidents while working in a clinic, or what I call, a bill mill. I have spoken out against the abuse I’ve seen and I was actually fired from that company for that very reason. ABA is a tool and how it is used is what makes it either good or evil. I do not use forced compliance, physical prompts, or other punishment techniques that were the “go-to” response for all my other colleagues. I was even written up because I refused multiples times to physically restrain small children, who although their parents signed the plan, did not deserve to have their human rights violated in order to gain temporary compliance. Unrealistic goals and dance monkey type programming, I never agreed with and still don’t. I work alone because it is the only way I can protect my people and ensure this abuse does not occur. I’m now in a doctoral program and I want others to know that I am fighting against the abuses in ABA from within. I’m also going to continue to fight for myself as well as other NeuroDiverse individuals. I was diagnosed at 10 with ADHD, GAD, and ODD. Diagnosed again at 30 with ADHD, GAD, MDD, and now, Bipolar was changed to BorderlinePD. I have been fighting advocating for myself since that age and I won’t quit. This gives me a unique perspective and I also am not very popular with others when I do speak up and demand change. I want people to know I see you, I hear you, I want to help change things for good. If that means not using ABA then I’m willing to do that.

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