ABA: The troubling history & legacy of autism’s most common therapy (pt 1)
Beginnings: From gay conversion therapy to autism treatments
The Dead Leaf butterfly (Kallima inachus) is a nymphalid butterfly found throughout Tropical Asia. With its wings closed (underside), Kallima inachus closely resembles a dry leaf with dark veins, easily camouflaged from predators in the natural environment. The average hiker would only see what looks like an old brown leaf—or likely not even notice it--as the insect sits, frozen, on a nearby branch. But when Kallima inachus opens its wings to take flight, it reveals a pallet of dreamy, luminous blues with a broad band of vibrant yellow and black wing tips, each dotted with white spots, known as oculi.
As humans, we camouflage too. Sometimes by choice and sometimes for survival.
For decades, many autistic children in the United States and Canada have been conditioned to camouflage through a Skinnerist therapy system called Applied Behaviour Analysis (ABA). ABA uses a system of rewards, punishments and repetitive drills known as discrete trial training (DTT), to gain “compliance” from autistic children, with the claim it can make autistic kids, in its founder Ole Ivor Lovaas’s words, “indistinguishable from their peers.”
Around the same time he popularized ABA in the 1970s and 1980s, Lovaas founded a similar form of therapy that he claimed could stop gay males from being gay: gay conversion therapy. While Lovaas’ method, which is not based in science, has been broadly disavowed in the context of gay men, it remains the most ubiquitous form of autism therapy in the US and Canada.
I’ve been wondering why.
A lucrative practice, with ethical and methodological concerns
In the United States and Canada, ABA is the most commonly funded system of autism therapy, although outside of the US and Canada, ABA is not widely used. ABA is rooted in the work of behaviourist B.F. Skinner, rewarding autistic children with treats for covering up their autistic traits (such as flapping or spinning) and punishing them with physical aversives when they don’t comply. The dyad of rewards and punishment range from a provider allowing/denying the child play time or taking away/giving back objects that are special to the child—to more severe measures, including locking children in isolation rooms.
According to Allison McCarthy and Daniel Wilkenfeld, who examined ABA for the Kennedy Institute of Ethics Journal, a central assertion of ABA is that:
“…small behaviors that are rewarded (or punished) will be repeated (or inhibited), and that such small changes can eventually build to radically altered behavior patterns. The focus is exclusively on using incentives and disincentives to alter behavior.”
This behaviourist practice is typically attempted through discrete trial training (DTT), where children are compelled by a therapist to repeat actions in 20-35 hours per week of intensive therapy sessions. If the action is done correctly, they receive a “reinforcer” (reward) and if it is done wrong, they receive an “aversive” (punishment). An example of DTT is a therapist showing a picture of a cup and repeats “cup, cup, cup”, using token rewards (“reinforcers”) and punishments (“aversives”) to coerce the child into repeating “cup”. Parents are also trained to do these repetitions with their child, during nearly all waking hours.
The ABA system segregates children by its very design. After spending their early childhoods separated from their peers in the segregated ABA clinic, many autistic kids are then streamed from ABA centre to the ABA-run special education classroom and then into ABA-managed group homes. It is a kind of pipeline effect that benefits the profession, which can access funds from families throughout the patient’s lifetime.
In one such segregated centre, the Judge Rotenberg Center (JRC) in Massachusetts autism providers have used a system of painful electroshocks delivered remotely to a belt around the student’s waist (called a GED). Despite statements from the United Nations and other human rights groups--and even an attempted ban by the FDA—the GED electroshock torture has continued at the JRC into 2024.
Far from being an outlier within ABA, the JRC’s use of electroshock aversives was approved by the international professional association of ABA providers (the Association for Behavior Analysis International, or ABAI) until 2023. The ABAI even invited representatives of the JRC to be featured guests at its 2021 conference at a symposium entitled “Challenging the FDA Ban on Electrical Stimulation Devices.” It was only after years of outcry from families and autistic activists that a slim majority of the ABAI voted to disavow the use of the GED in 2023.
It may seem surprising that the ABA industry refused to disavow a shock torture device, even after the FDA attempted to ban it. But the use of the GED is rooted in the ideology of ABA, which focuses on the goal of compliance at any cost. When the ABA industry began to disavow the GED in 2023, it gave momentum to a new movement that sees the behaviouristic, compliance-based approach as the wrong way to treat autism. The problem for the ABA industry is that without aversives and rewards, there really wouldn’t be much left to distinguish ABA from other therapies.
The stakes are high in the battle around ABA. According to the Autism Investor Summit, autism services cost Americans $250 billion in 2018, with much of that money funnelled into the ABA industry. In a more conservative estimate for the same year, Coker Capital Advisors, an investment firm, estimated annual revenue for ABA centres in the US to upwards of $10 billion, with another $7 billion in value for major school-based providers. Intensive ABA (often known as Intensive Behaviour Intervention or IBI) is the most expensive and energy-consuming form of ABA, costing between $20,000 and $80,000 per family, per year.
Part of ABA’s staying power has come from its intensive lobbying to entrench itself in public policy. Over the past two decades, ABA providers have united as an interest group to persuade lawmakers in all 50 US states and across Canada to mandate insurance companies and public insurers to fund ABA. This is extraordinary because no other autism therapy is mandated nation-wide in either country. It is also extraordinary because ABA is not mandated in jurisdictions outside of the US and Canada.[1] (More on this later in the chapter.)
While in one corner of the battle over ABA stands a multi-billion dollar industry, in the other stands the parents, service providers, researchers and autistic people who have been critical of ABA. The #StopTheShock movement has focused on stopping shock torture at the Rotenberg Center. The Alliance Against Seclusion and Restraint, a parent-led group, opposes ABA, stating at its root ABA supports abusive classroom practices. The neurodiversity movement has taken a zero tolerance approach to ABA, with self-advocacy groups such as the Autistic Self Advocacy Network (US) , Autistic Inclusivity (US) and Autistics for Autistics (Canada) all calling for an end to ABA.[2]
Researchers have also weighed in on the issue. While there has never been a shortage of research by those in support of ABA (with research commonly undertaken by ABA centers and practitioners themselves and published in the 3 major industry journals), reviews by entities outside of the ABA industry have revealed problems.
In 2003, Gernsbacher and colleagues wrote one of the first papers that collected and analyzed methods from within the field. It cited a New York State Guidelines document that concluded of the hundreds of ABA papers published, only two met the standards for experimental design--and neither of those employed control groups, which, Gernsbacher wrote, are typically “a core feature of scientific credibility in treatment studies,” (cited in Broderick, 121). (See the next section for more recent work questioning the methodology of ABA research).
Ethicists are also exploring the issues around ABA. For example, McCarthy and Wilkenfeld argue that ABA “manifests systematic violations of the fundamental tenets of bioethics. Moreover, the supposed benefits of the treatment not only fail to mitigate these violations, but often exacerbate them.”
“Our contribution is to argue that, from a bioethical perspective, autism advocates are fully justified in their concerns-the rights of autistic children and their parents are being regularly infringed upon. …[E]mploying 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.”
Despite the controversy around and resistance to ABA, it has continued to dominate American and Canadian autism services. To get at why, we need to understand the origins of the ABA ideology.[4] What is the main message of ABA—and how does this message influence other autism services and therapeutic practices? Will ABA’s “conversion” approach remain sustainable if families and autistic people reject the ideal of compliance-at-any-cost and turn their focus towards quality of life?
The first alternative to the asylum
Ole Ivor Lovaas, the father of modern ABA was a mid-late 20th century behaviourist who also co-founded a form of gay conversion therapy.[5] Lovaas was most active as a researcher in the 1960s, 70s and 80s, founding a program called the Young Autism Project, a form of autism therapy similar to his Feminine Boy Project, which claimed to be able to stop boys from being gay, through behaviourist techniques.
Lovaas was inspired by B.F. Skinner, who believed in using operant conditioning to attempt to modify behaviour through reinforcement and punishment. Lovaas also took inspiration from the punitive environment of the residential institution (asylum). In many ways, he used the tools of the asylum and moved then to clinical practice, while claiming to parents that his approach was the only way they would be able to keep their children out of the residential institution system.
In 1987, Lovaas published a small, flawed study claiming that autistic children who had participated in ABA had since become “indistinguishable from their [non-autistic] peers.” As Bottema Beutel has pointed out “this finding has not replicated.” Yet the hope/hype that Lovaas built has continued to today. His was a pitch that was steeped in his own ideology, with the flip side of that hope promised to parents being a threat of doom if families did not bring their children to his practice. Choose ABA—or choose the institution.
Steve Silberman, whose book Neurotribes chronicles the changing definitions and treatment of autism, has described the environment of residential institutions and their effects on children, suggesting that to some, children’s trauma responses to institutional abuses became associated with autism itself. Behaviors caused by institutionalization under brutal conditions were described as part of the “‘natural’” course of autism,” Silberman told The Sun magazine in an interview. He described life for kids in the 1950s and 1960s institutions this way:
“Some kids were placed in state schools for children with intellectual disabilities, and others were put in locked wards for adult psychotics. These autistic kids were often subjected to seclusion, restraint, and physical punishment by clinicians who did not understand their condition. The head of children’s psychiatry at Bellevue Hospital in New York City, Lauretta Bender, administered electroconvulsive therapy to autistic patients and also insulin-shock therapy — administering overdoses of insulin to put them into a short-term coma.”
Institutions had used Skinnerian principles to develop token economies where inmates’ behaviour was reinforced with tokens that could be exchanged changed for items or privileges, much like Lovaas’s methods. But the Lovaas Approach still appealed to concerned parents were seeking an alternative and who were increasingly exposed to media promotions of Lovaas’s techniques.
“Little Monsters”: Lovaas’ portrayal of autistic children
Lovaas and his supporters channeled some of the energy of the de-institutionalization movement to position ABA as transformative. “The treatment used to consist of putting them in full restraints,” Lovaas told Paul Chance, who interviewed Lovaas for a 1974 Psychology Today interview. Chance, who valorized Lovaas in his article as “a poet with a cattle prod”, confirmed Lovaas’ belief that he had saved children from institutions through his methods, writing:
“He shocks them because the alternative is to tie them down to a bed and let them vegetate.”
Lovaas’s descriptions of autistic children are difficult to read today. In a 1974 interview with Psychology Today he described autistic kids as “monsters, little monsters,” with the solution to their “behaviours” being to “Spank them, and spank them good.” Many of the children he was working with had developed maladaptive, self-injuring behaviours from living in abusive institutions, behaviours Lovaas ascribed to autism rather than as a trauma response. His solution to this trauma was, seemingly, to create more of it, with the assumption that children would eventually comply out of terror:
“We stay close to them and when they hurt themselves we scream ‘no’ as loud as we can and we look furious and at the same time we [electroshock] them.”
When asked whether he found it upsetting to hit a child, Lovaas described his own view that the physical abuse of the children was a kind of bonding experience: “After you hit a kid you can't just get up and leave him; you are hooked to that kid.” Lovaas’ team used electric shock, electrified floors, cattle prods, food and water deprivation, as well as many other forms of violence, perhaps best summed up by title of a 1965 Life Magazine profile on ABA, entitled: “Screams, Slaps and Love”.
Lovaas dehumanized autistic children, telling the Psychology Today reporter that a therapist has to “start pretty much from scratch” with an autistic patient:
“You have a person in the physical sense — they have hair, a nose and a mouth — but they are not people in the psychological sense. One way to look at the job of helping autistic kids is to see it as a matter of constructing a person. You have the raw materials, but you have to build the person. [emphasis added].”
The ABA approach was alienated from the field of psychology, a gap that widened the more extreme the industry’s claims became. As historian Alicia Broderick uncovered in her research on Lovaas, the behaviourist had initially been relatively conservative in his claims about what ABA could accomplish. But by the 1980s, Lovaas had begun to claim he was not only able to get children out of the institutions, he could also make many autistic children “indistinguishable from their [non-autistic] peers,” outside of the institution.
Lovaas’s work had helped lay the groundwork for a belief system as well as an industry, complete with its own self-reflexive research journals, committees and lobby groups. One of the early journals was the Journal of Applied Behaviour Analysis. As Broderick observed, the journal departed from others in the field of child development at the time by accepting advertisements for behavioural technologies and products. These included sensory deprivation chambers and shock boxes. In one ad from fall of 1968 that targeted autism providers, the Farall Instrument Company advertised a range of shock torture devices (Broderick, 41).
“A true wireless shocker. By using radio control, you can deliver a shock to a patient up to 1000 feet away with no connection. Now behavior modified in the laboratory or office situation may be subject to…training more closely approximating the situations to which the behaviour must be transferred (Quoted in Broderick, 43).”
The gay conversion connection
As Lovaas repurposed the tools of the asylum for clinical use on autistic children, he was also building a program of gay conversion therapy with his former doctoral student, George Rekers. The Clinic Program for the Evaluation and Treatment of Childhood Gender Problems, based in UCLA’s psychology department, had Lovaas as principal investigator and Rekers as project director. He received $218,945 from the National Institute for Mental Health for a project to “remake” boys to be more masculine and less feminine.
Kaytee Murphy recalled her early concerns that led her to enroll her 5-year-old son in the program; namely, that he was playing with dolls and eschewing traditional masculinity. One day she saw a doctor on television recruiting young boys for the government-funded program. "He was naming all of these things; 'If your son is doing five of these 10 things, does he prefer to play with girls' toys instead of boys' toys?' Just things like this," she said. "Well, him being the expert, I thought, maybe I should take Kirk in.”
Kirk became the subject of 17 papers by Rekkers and/or Lovaas. In his 1974 paper “Behavioral treatment of deviant sex-role behaviors in a male child” Lovaas and Rekkers described a 10-month course of treatment for the 5-year-old Kirk (given the pseudonym Kraig) who had enjoyed “feminine play behavior”. In the clinic setting, the therapy involved “planned ignoring,” an ABA tactic that remains popular today. Kirk’s mother, Ms. Murphy, was told to ignore her son when he played with feminine toys and to compliment him when he played with masculine toys. If he got upset that she was ignoring him, she was instructed to continue ignoring him.
At home, the behaviour plan included instructing Kirk’s parents to use a token economy (employing poker chips), rewarding good behaviour with privileges and bad behaviour with physical abuse and withdrawal of attention (planned ignoring), plus tokens for a dizzying assortment of activities including brushing his teeth and doing chores. According to the case study, blue chips were given for masculine behavior and would bring rewards, such as candy. But the red chips, given for effeminate behavior, resulted in "physical punishment."
Kirk’s siblings remember the treatments. His brother, Mark was encouraged to be part of the token system as well. His sister told CNN in 2011 that the beatings were extreme. After, she would go to Kirk's bedroom and "lay down and hug him and we would just lay there, and the thing that I remember is that he never even showed anger. He was just numb." When he returned home each day, Mark often looked for the chips, which were kept in plain sight. "You looked and were like, 'What's the chip count today? What happened? What changed? How bad is it going to be?' And it was always bad. There was whipping every Friday night. There was no way out of it.”
Lovaas and Rekers described the results of the 10-month behaviour intervention as follows:
“Before therapy, Kraig was a ‘cry-baby,’ being afraid to hurt himself in rough games; after the reinforcement therapy, Kraig was playing with ‘roughneck’ Kenny next door. …Kraig is no longer fussy about color-coordinating his clothes or keeping his hair neat, however our clinical impression is that he still may be less skilled in some desired masculine play behaviors (e.g., throwing, catching and batting a softball.”
Lovaas and/or Rekers would go on to write positively about their experiments on Kirk for many years. Rekers became a founding member of the Family Research Council, a faith-based organization that lobbies against gay-rights issues. As recently as 2009, a book Rekers co-authored, "Handbook of Therapy for Unwanted Homosexual Attractions," cites “Kraig's” case as a success.
Many who read Rekers’ book didn’t know that six years prior to its publication, Kirk Murphy had taken his own life at the age of 38.
It was a detail that, in subsequent versions of the book, Rekers always left out.
In 2011, when Kirk’s family spoke with CNN about his life, his mother said she believes the conversion therapy destroyed Kirk's life. "I blame them for the way his life turned out," she said. "If one person causes another person's death, I don't care if it's 20 or 50 years later, it's the same as murder in my eyes.”
At the time that the Murphy family spoke to CNN, Rekers had recently been photographed the year prior with a male escort, whom Rekers had hired to travel with him in Europe and he lost his long-held positions in the anti-gay movement.
Reading Lovaas and Rekers’ gay conversion projects, alongside Lovaas’ work on ABA for autistic children, one can see similar threads. As Jake Pyne, a professor of Social Work at York University, has pointed out, Lovaas projected a doomed future for children whose parents didn’t undertake either of his therapies. In Pyne’s words, Lovaas drew scenarios such as “future incarceration, either institutionalization for autistic children or arrest for gender non-conforming children who live their lives as homosexual or transsexual,” as well as a constant theme of being ostracised by peers.
The post-institution era, normalcy and “recovering the lost child”
In Lovaas’s era, residential institutions began to rapidly depopulate as the disability rights movement began to have success in their calls for humane housing for disabled individuals. But because de-institutionalization policy was so closely aligned with austerity, the work of de-institutionalization was only partly done. Institutions were closed, but policymakers did not deliver on policies for independent supported living for autistic and developmentally disabled people.
Even as some people with physical disabilities were gradually attaining the legal rights to live independently and choose their own personal support workers and have access to public spaces, intellectually disabled people were denied these rights.[7] The social terror of having a non-conforming child (whether gay or autistic) accelerated in the Cold War. As health historian Matthew Smith notes, this ushered in “a huge shift” in educational policy in the United States, focusing on its performance on the global stage. Lovaas’s message about making autistic children “indistinguishable from their peers” was compelling to many parents navigating a shifting education system.
As the era of standardized testing--and standardized lives--took off, so did the disability rights movement. Notably, the Education for All Handicapped Children Act was passed by the US Congress, guaranteeing the right to education for all disabled children. In 1987, Lovaas published a paper on The Young Autism Project, claiming that ABA therapy had helped nine of 19 children have “normal functioning” and “recovery to normalcy”. Lovaas’s definition of becoming “normal” was successfully completing first grade.
But his methodology was flawed. For starters, the majority of children (10) in Lovaas’s study were actually not able to complete first grade. Also, every child in the study was receiving ABA so there was no control group to compare against. In Broderick’s view, Lovaas’s assertion that the nine children had “recovered” from autism by getting through first grade is a “slippery and non-reliable outcome measure”, yet it laid the groundwork for a powerful marketing theme of the industry: Recovery.
Lovaas coupled his claims of recovery from autism with a kind of cost-benefit analysis to justify the high costs of full-time ABA. He claimed that the lifetime “costs of autism” could be slashed with an initial investment in ABA, writing in 1987:
“The assignment of one full-time special education teacher for 2 years would cost an estimated $40,000, in contrast to the nearly $2 million incurred (in direct costs alone) by each client requiring life-long institutionalization.” (quoted in Broderick, 69.)
It was crucial that Lovaas contrast his new concept of recovery and hope with only one other scenario: institutionalization. In doing so, he positioned ABA as a singular framework of hope and help for families. ABA’s market grew exponentially throughout the 1980s and 1990s as the Diagnostic and Statistical Manual (DSM) of the American Psychological Association broadened its definition of autism to include many more signs and conditions.
In the absence of robust data, ABA supporters turned to anecdotes. One of the earliest promoters of ABA as a “recovery” tool was Catherine Maurice, the pseudonym used by a mom whose 1993 memoir A Family’s Triumph Over Autism described using ABA at home with her two children.
“It took us a few days to begin to say the word recovery aloud, to begin to talk about it. It seemed impossible, given everything we had read and heard about it. Once we had adjusted to hope, there was no turning back. We set our sites for the mountaintops. Anne-Marie would be whole and normal. … She would recover (quoted in Broderick, 68).”
Maurice’s testimonial become a best-seller and, as Broderick notes, copycat books were published. News media picked up on the stories and a whole genre of testimonial-style ABA marketing took hold. Parent testimonials were backed by single case studies in industry journals that looked like science to many families. As one parent told Broderick: “It [ABA] is the only thing that’s been scientifically proven to work in recovering kids with autism—why would we do anything else?” (cited in Broderick, 86.)
The state of ABA today
Lovaas and Rekers’ gay conversion therapy remained popular in some parts of North America for decades, until recent years when some states and provinces have begun to ban the practice. There are no state bans on ABA for autism, however.
Neither Lovaas nor Skinner have been repudiated by the ABA industry; in fact, they’re frequently cited in its contemporary research. A 2019 promotional video that appears on the website of the Massachusetts Association for Applied Behaviour Analysis features a larger than life photograph of Skinner in the background during most of the video. Skinner’s legacy, like his visage, are ever-present in the field. The Lovaas Institute and “the Lovaas method” are still a part of much ABA practice and ABA practitioners continue to cite Lovaas in their work.
The legacy of Lovaas’s early shock torture methods is the graduated electronic decelerator (GED), a painful electrical shock device used at the JRC. As journalist John Summers described it in the Boston Review:
“From a battery pack strapped around students’ backs, the decelerator’s wires travel under students’ clothing to their arms, legs, and torso. The shock, triggered by remote control, pulses through cathodes fastened to the skin. This is an entirely different treatment than electroconvulsive therapy for severe depression; the sole purpose of electric skin shock is to inflict pain.”
In 2002, Andre McCollins, a JRC student, was restrained and shocked 31 times for 7 hours because he had not taken his coat off quickly enough when he arrived at the school. McCollins suffered third degree burns and became catatonic, remaining traumatized by the event. His mother, Cheryl McCollins, removed him from the JRC and filed suit in a case that went to trial in 2012.
Meanwhile, the Association for Behaviour Analysis International (ABAI) featured leaders of the JRC at its conferences in 2015, 2019, 2020 and 2021, when the group hosted a symposium entitled “Challenging the FDA Ban on Electrical Stimulation Devices,” presented by JRC employees.[6] Support for the GED perhaps reflected the Lovaasian idea that punishment and pain are an essential part of autism care, with normal ethics of care being suspended.
It’s hard to imagine reform in an industry that’s held tight to a man like Lovaas as its hero. When he passed away in 2010, the Association for Science in Autism Treatment (ASAT), an ABA organization, dedicated an issue to honouring Lovaas’s vision of autism services. In its introduction, the editors wrote:
“While his work may have generated controversy and criticism, few great thinkers have followed such a visionary path without suffering detractors along the way.”
ASAT Board member Tristram Smith, who worked with Lovaas, described their time together as “exhilarating.”
“Lovaas showed that children with autism did not need to be confined to institutions. A generation after Lovaas‘s (1987) groundbreaking study, his intervention remains the most studied and arguably most successful comprehensive early intervention program for children with autism.”
The narrative of Lovaas as a saviour is quickly evaporating for families, many of whom now push for humane approaches supported by the neurodiversity movement. But the ABA marketing machine has entrenched the therapy within the machinery of autism services, in large part through insurance mandates, making it harder for better services to be funded and supported at schools and in the broader community. In the next section, I take an in-depth look at the marketing of ABA to parents, policymakers and insurers.
This is part 1 of a 3-part series on the history and impact of ABA, the most popular autism therapy in the US and Canada.
[1] I describe the ABA lobby’s efforts globally in detail in part 2.
[2] Disclosure: I was a co-founder of Autistics for Autistics and have been active in the group from 2017-present.