This letter to the ASHA Leader Editor is being circulated for signatures from speech-language pathologists who share the expressed concerns regarding the article “Building Working Relationships With Applied Behavior Analysts” that appeared in the April 2020 issue of the ASHA Leader. The letter is sponsored by the Therapist Neurodiversity Collective (SLPNDC) and authored by Therapy Chair for University Involvement, Dr. Amy Lustig, Ph.D., CCC-SLP.

CCC-SLPs: Add your signature to this letter here

To the Editor:

The above-named article, which proposes that cross-disciplinary collaboration best serves the interests of clients of speech-language pathology (SLP) and applied behavior analysis (ABA) services, is built on several faulty premises. First, it assumes a reciprocal inability across professions to stay within each of our respective practice parameters. From a purely practical perspective, this is absurd, given that ABA services are reimbursed at up to 40 hours per week, and SLPs are fortunate to receive compensation for 1 or 2 weekly visits. Second, it suggests the breakdown in cooperation across professions is associated with poor SLP awareness of ABA practices, and that SLPs bear the burden of improving our knowledge of behavioral terminology and intervention. However, it has become excruciatingly clear to anyone who is professionally engaged with these clinical populations that the ABA profession openly and enthusiastically encourages its members to target therapy goals, such as expressive / receptive language and motor speech production, that are clearly out of their professional scope of practice.1 As a group, ABA providers have demonstrated their inability to establish appropriate boundaries and to recognize the limits of their professional competencies. The burden of responsibility for creating and enforcing these necessary professional boundaries falls on the SLP, eclipsing the value of, say, clarifying what the term “autoclitics” means.

Perhaps the most troubling aspect of this picture concerns the implicit approval by ASHA of the core ABA practices which, driven by an overall poorly-designed and biased research literature, are steeped in clinician-driven agendas, reward/punishment reinforcement systems, and imposed behaviors such as forced eye contact and demanded food intake that elicit client discomfort and resistance, which are then ignored as part of the behaviorist protocol to “extinguish” the “unwanted” resistive behaviors. There is a sizable and growing cohort of evidence, from anecdotal to peer-reviewed reports, that recognizes participation in ABA therapy can cause outcomes ranging from distressing to traumatizing.2,3 With the caveat that not all ABA providers are associated with such poor results, the fact remains that enough evidence for these exist such that ASHA, as a professional organization ostensibly concerned with client welfare, bears a responsibility to the public good to acknowledge that participation in ABA therapy carries a reasonable risk of adverse outcomes, and to encourage careful consideration before making that decision. To date, ASHA has made it clear that it has absolutely no interest in taking such a public stand.

ASHA has recently stepped up to provide support to state associations where ABA providers have attempted to encroach at the level of the professional license, and this has been appreciated. However, the organization’s failure to establish a clear perspective on the current state of ABA treatment, to vigorously advocate for appropriate professional limits where scope of practice is concerned, and to acknowledge the very real potential for negative outcomes associated with the therapy, are egregious oversights.

1California ABA provider advertising language treatment services, now a frequent and inappropriate goal of ABA providers. https://www.centerforautism.com/services/therapy-programs/child-services/

2Reichow, B., Hume, K., Barton, E.E., & Boyd, B.A. (2018). Early intensive behavioral intervention (EIBI) for young children with autism spectrum disorders (ASD). The Cochrane Database of Systematic Reviews, May 2018(5). doi: 10.1002/14651858.CD009260.pub3

3The Department of Defense Comprehensive Autism Care Demonstration: Quarterly Report to Congress (2019). United States Department of Defense, Second Quarter, Fiscal Year 2019.

https://health.mil/Reference-Center/Congressional-Testimonies/2019/06/10/Annual-Report-on-Autism-Care-Demonstration-Program

About the Author: Dr. Lustig has been a licensed SLP for over 20 years and worked as a mental health therapist for 10 years before that. Her clinical strengths and passions concern adults with complex presentations, and she specializes in addressing the consequences of neurogenic and neurodegenerative diseases and injuries. Dr. Lustig has worked across multiple settings, including as an SLP in the VA hospital systems in Philadelphia and Pittsburgh, PA where she served on the Polytrauma team and was filmed for the “My Parkinson’s Story” instructional video series; as a clinical researcher; as a private practice owner; and currently as an assistant professor at Salus University in Elkins Park, PA, training graduate SLP students. In addition to maintaining a limited private practice (Restorative Speech & Swallow, LLC), she owns a consulting service called Kind Transitions, which she created in 2018 in an attempt to fill a gap in support for individuals and families coping with decision-making during difficult, transitional times in chronic and progressive illness.