ABA Therapy and PTSD

The “New ABA” is still all about compliance.

by Amy Grant, M.S., CCC-SLP

I was called “unethical” by a professional colleague today.

The reason may surprise you—I said “ABA is abuse”.  My peer was naturally taken aback because they are an SLP-BCBA and “would never dream of abusing a child.” I always find this rebuttal interesting because we usually don’t hear about people walking around admitting to abusing people; even overt predators somehow convince themselves that they are helping their victim. The sanctimonious SLP-BCBA told me that it was the “old ABA” and not “new ABA” that was harmful, and then only a small fraction of the time.  She accused me of “throwing the baby out with the bathwater” (I still don’t really understand how this idiomatic expression applies here) and she further went on to insist that there is “no way ABA could cause PTSD in people with Autism.” (She really meant “Autistic people,” I am sure.)

Overload – “This is too demanding! I need a break!”

Humans have an amazing innate response to survive when they are faced with a threat or danger, fight, flight, or freeze. This is an automatic nervous system response. The fight and flight responses are triggered by the sympathetic nervous system, and the freeze response is triggered by the parasympathetic nervous system. Both of these systems combined make up the autonomic nervous system (ANS). When one of the responses is dispatched the human body simultaneously releases adrenaline and cortisol. If the ANA is only triggered once, for example maybe you almost rear-end someone while driving, your body would typically return to a calm state in 20-30 minutes. But, when the ANS is repeatedly triggered without time to regulate and return cortisol levels to a manageable level, what results is trauma-induced post-traumatic stress disorder (PTSD).  (Cleveland Clinic, 2019)

The BCBA ignores the child’s visibly growing state of overwhelm, in pursuit of behavior modification. Because the student is not permitted to self-regulate by walking away for a minute or taking a break, a meltdown ensues.

Now, let’s about talk Post Traumatic Stress Disorder (PTSD):
Depersonalization disorder (DPD), a dissociative subtype of PTSD was identified secondary to neuroimaging evidence linking it to an early life history of adversity and a combination of frontal activation and limbic inhibition.  (Spiegel, et al., 2013) DPD often occurs after the individual is deprived of sensory stimulation. Common triggers of depersonalization include severe stress, particularly from emotional abuse and/or neglect during childhood. (Mayo Clinic, 2017)

Probably the most severe type of PTSD is Complex Post Traumatic Stress Disorder (CPTSD). In contemporary research, CPTSD is becoming more understood and is identified in individuals that have repeated exposure to trauma happening primarily in childhood and at the hands of a caregiver.  Commonly, emotional outbursts are symptoms of CPTSD.  (Wilson, 2004)

Now that you have had a crash course in PTSD, let’s apply this information:
As a trauma-informed therapist, it is heartbreaking to see how proud ABA therapists are of their ABA goals, brazenly showing them off on the internet. A quick Google search yields a goldmine of examples to prove my point. Here are behavior goals for a hypothetical student named Keoni:

(Amanda N. Kelly, 2017)

Looking at Keoni’s behavior plan written by a “Ph.D., BCBA-D, LBA” who self proclaims to be an “Ethical Advocate for Accurate Application & Dissemination of Behavior” I notice the obvious goal of complying with a command from an authority figure. Let’s (set aside the grooming for future abuse part of this goal, for a moment) and highlight the following;

Now let’s take all of the above and apply it to a common occurrence for an Autistic child in the sensory overwhelming environment of a school classroom.

What BCBAs call “escapism” is really sensory overwhelm. But both the child’s emotional state, as well as her state of overload, are ignored in the pursuit of extinction of the student’s challenging behavior and compliance.

When an Autistic child’s sensory system becomes overwhelmed, the child may first naturally attempt to self-regulate.  Perhaps, in an effort to self-regulate, the Autistic child will attempt to pace back and forth in a pre-calculated pathway in the classroom. The BCBA interprets the behavior of the child seen getting up from their assigned seat and failing to follow the command of “stop” or “come back,” not as a communicative attempt (in self-advocacy) for the need of self-regulation, but rather as a function of her behavior, in this case, “escape” and non-compliance. The BCBA then determines that intervention is necessary.

This decision will significantly escalate the situation, and the result is that the ANS system kicks in, triggering the child’s fight, flight, freeze response.  But, the BCBA ignores that child’s nervous system’s response because their job is to force compliance of following the commands of “stop,” “wait,” or “come back” in order to extinguish the behavior function of “escape.” The authority figure actively stands in the way of the child’s self-regulation attempts and reignites the child’s fight, flight, freeze response, again, and again, and again. Meanwhile, the child’s body releases adrenaline and cortisol over, and over, and over, until their little body can’t handle anymore and then they go into meltdown.

At this point, the situation is massively escalated and most likely results in the removal of the Autistic child from the classroom and possibly with the child being restrained or secluded.  Now we arrive at CPTSD full circle. Complex PTSD is caused by “repeated exposure to trauma happening primarily in childhood and at the hands of a caregiver.” (Wilson, 2004)  After repeated cycles in the classroom, the Autistic child begins to develop PTSD because the neurotypical BCBA is focused on the function of behavior and the compliance of the child, and not what the child is communicating with their behavior. This is just one example of an ABA goal, but these types of goals are routinely written for both school and home environments to be targeted during the recommended 20 – 40 hours of ABA per Autistic child that is strongly recommended (and often “prescribed” by BCBAs so it looks as if the ABA is medically necessary) as the “gold standard” of therapy.

Can you imagine every waking moment of your life being forced to ignore your innate survival responses in the pursuit of compliance? Chemically, there is only so much our bodies can handle.

The imperious SLP-BCBA may come back and say, “Wait, correlation does not equal causation.”

Well, as a trauma-informed speech-language pathologist, my response is simple;

I know without a doubt that ABA is traumatizing. I know without a doubt that ABA causes PTSD (both complex and DPD). Do you want to know my secret? I listen to AUTISTIC people’s lived experiences.  If advocating for the rights of Autistic people and all other disabled people who are being routinely abused by ABA is unethical, then take my license to practice. I will fight ABA until I am a pile of dust.

Resources:
Amanda N. Kelly, P. B.-D. (2017, June 25). https://drive.google.com/file/d/0B2hfhSfTdObISndocnlGVTMxTWc/view. Retrieved from Behaviorbabe: Ethical Advocate for Accurate Application & Dissemination of Behavior Analysis: https://www.behaviorbabe.com/behavior-plans
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5). American Psychiatric Publishing.
Cleveland Clinic. (2019, December 9). What Happens to Your Body During the Fight or Flight Response? Cleveland, OH. Retrieved from Cleveland Clinic.
Mayo Clinic. (2017, May 16). Depersonalization-derealization disorder. Retrieved from Mayo Clinic: https://www.mayoclinic.org/diseases-conditions/depersonalization-derealization-disorder/symptoms-causes/syc-20352911
Spiegel, D., Lewis-Fernández, R., Lanius, R., Vermetten, E., Simeon, D., & Friedman, M. (2013). Dissociative Disorders in DSM-5. Annual Review of Clinical Psychology, 9, 299-326. Retrieved from https://doi.org/10.1146/annurev-clinpsy-050212-185531
Wilson, J. P. (2004). PTSD and Complex PTSD: Symptoms, Syndromes, and Diagnoses. In I. J. Eds.), Assessing psychological trauma and PTSD (pp. 7-44). The Guilford Press.

Amy Grant, M.S., CCC-SLP.
Pronouns: she/her. 
Owner and Director – Therapy Center of Buda
ASHA Certified Speech-Language Pathologist since 2005
After gaining experience in early childhood intervention and outpatient pediatric care, Amy opened the Therapy Center of Buda in 2009, which serves the neurodivergent pediatric population through an interdisciplinary team of speech-language pathologists and occupational therapists.  Amy serves as the Clinic Director and lead SLP, and supervises assistants and administrative staff.  She practices family-centered, child-led therapy that embraces the neurodiversity paradigm, with a foundational dedication to serving her clients and families with compassion and respect as well as advocating for human rights for all. Amy received extensive training on administering the Autism Diagnostic Observation Schedule (ADOS-2) and provides assistance to pediatricians and neurologists in identifying Autism from the unique perspective of a neurodivergent SLP that embraces neurodiversity. 
LInks:
Website: www.therapycenterofbuda.com
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Twitter: @TherapyCntrBuda
LinkedIn: www.linkedin.com/in/amygrantslp

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