Autism and ABA therapists: Why are some better than others?

By Nestor Lopez-Duran PhD

The research on ABA is consistent: ABA is a highly effective intervention for autism. What do I mean by that? That on average, kids with autism exposed to ABA will improve more than those who do not receive this intervention. However, the key word here is on average. The research is also very consistent in showing that for some children ABA may not be as effective.

Why does ABA work for some children with autism and less so for others?

This question is not unique to ABA or autism. Across the board, psychological interventions do not work for everyone. In fact, most interventions that we consider to be very effective barely work for 50% of those affected.

Why is this the case? Why is it that some people respond to psychological interventions while others do not?

Researches attempting to answer this question have often focused on what they call contextual or individual variables. For example, is it that the therapy works best for females than males, or for those living in urban settings as compared to rural ones? etc., etc., etc.

But the answer, or at least part of the answer, may not be with the individual (patient) but with the therapist. You could say that simply some therapists are better than others. There is no denying this. But there is another reason that is significantly more controversial: whether the therapist does therapy as the therapy was intended to be done or instead makes up his/her own version on the premise that flexibility is good.

Let me explain why this is controversial (and stay with me, I will get to the ABA issue soon). There is a consistent finding in psychotherapy research. When the research is conducted at academic centers with highly controlled randomized clinical trials using research therapists the effectiveness of the therapy is significantly better than when the research is conducted in the community using real practicing therapists. That is, specific interventions work much better in research settings than in more real-life clinical settings.

Some have explained this discrepancy by arguing that the patients used in research centers are not representative of the patients going to community clinics. For example, for years, clinicians have argued that patients at research centers are selected to be clean in their diagnosis, such as when only patients with major depression (but without anything else) are included in research on a therapy for depression. The argument is that in the real world, very few people have ONLY major depression. But this argument, albeit persuasive and clearly sticky, does not reflect reality. Since the mid 90s research patients are not clean in diagnosis and instead have all of the characteristics of community patients. In fact, it would now be difficult, if not impossible, to get funding for a research grant that evaluates the effectiveness of an intervention if the proposed population does not reflect the population in the community. I am currently collaborating in 2 studies of interventions for child depression and in both studies the patients look exactly like the patients seen in the community.

So what then could be the reason research therapists appear to be more effective than real-life therapists?

I believe the research is pointing to one factor: FIDELITY.

Fidelity refers to the extent to which a therapist follows the guidelines (or the dreaded word manual) of the therapy as it was originally conceived. At research centers, fidelity monitoring is an ongoing intense process. That is, research therapists are monitored to make sure that they are implementing the therapy as intended without making up their own version or significantly adapting the original plan. This does not mean that these research clinicians are not flexible within a therapy session (some community clinicians incorrectly believe that following a manual means reading from a script in a robotic fashion, which is incorrect). Instead, fidelity means following a plan and implementing the therapy as intended. However, at the community-level, fidelity monitoring is non-existent. Actually, I would argue that fidelity is a taboo word and adhering to a manualized approach is viewed as undesirable because it is seen as too rigid or too restrictive of the therapists own expertise. Many real-life clinicians simply do not implement therapists as they were developed and believe instead that their eclectic or flexible approach is better. I argue those who hold such views are mistaken and that it is precisely the high fidelity adopted by research therapists that makes them more effective.

And here we finally get to the issue of ABA therapists. Recently, there was a brief research report in the Journal of Autism and Developmental Disorders that touched on this issue. The researchers wanted to know whether allegiance to ABA and thus fidelity to the ABA treatment protocol on the part of the therapists predicted how effective the therapy was. To this end, the researchers provided an allegiance questionnaire to the clinicians that measure how much they truly believe in ABA and how much they have criticisms of ABA as intended, which would result in clinicians making their own adaptations to the intervention. Not surprisingly, children who received the ABA intervention from the clinicians who had highest allegiance to ABA (those who believe most in ABA) had significantly better outcomes in regards to their daily functions than did kids who received treatment from clinicians who had more concerns about ABA.

So the question then for parents providing ABA to their kids is how much does your clinician truly believe in ABA and how much does he/she follow the ABA protocol as intended? And is it possible that part of the reason that ABA is sometimes not effective in some people is simply that sometimes ABA is not provided as intended because the therapists feel that their own adaptation is best?

The reference:

Klintwall, L., Gillberg, C., Bölte, S., & Fernell, E. (2011). The Efficacy of Intensive Behavioral Intervention for Children with Autism: A Matter of Allegiance? Journal of Autism and Developmental Disorders DOI: 10.1007/s10803-011-1223-z