We Know It Is Difficult—But Let’s Talk Behavioral Therapy
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We Know It Is Difficult—But Let’s Talk Behavioral Therapy

Finding the best way to manage difficult and challenging behaviors is a common concern among families in the child neurology community. This is partly because many assume Applied Behavioral Analysis (ABA) is the only approach available. ABA focuses on two things. The first is reinforcing positive behaviors. The second is decreasing unwanted behaviors. It is the go-to option offered in the United States. It is used by both early-intervention programs and schools.

But what if you have concerns about ABA? What if ABA is not working for your child?

There are alternatives to ABA. There are also new ways to approach ABA. And these options may be more effective for your child.

A lot of information about behavior therapy is available on the internet, but it can be biased or lacking scientific evidence. We know it is tough to navigate this information on your own. We are here to help. We want to empower you. We provide some information on this topic below to help you make good decisions for your child and family.

What Can Cause Challenging Behavior?

A Variety of Causes

Let’s start by talking about causes. What causes challenging behavior? It is often attributed to autism. But it does not always stem from autism. It can accompany various neurologic differences. In some cases, a child meets autism criteria due to their behavior. This can happen even when the child does not have autism. It is important to first dig into the behavior’s actual cause.

Finding the source of a behavior can be hard. Many things may contribute. Examples include:

Cognitive delays

Communication challenges

Cortical visual impairment

Motor planning function

Movement disorders

Seizure activity

Medication side effects

The Need for Support

Children facing challenging behavior need support. Eileen Devine is a licensed social worker and she is a neurobehavioral support coach. She works with parents and children who have differences in brain function that can cause difficulty with simple tasks. She says, “When individuals with these diagnoses are not provided with the accommodations that support them in these lagging cognitive skills, we see challenging behavioral symptoms result.”

Differences in brain function can cause challenging behavior. Consider these examples:

Limited verbal communication

This can cause frustration with communication. The frustration might be expressed through vocalizations, biting, or social withdrawal.

Cognitive delays

Intellectual or emotional delays can lead to behaviors appropriate for a younger child. Examples include having a temper tantrum or hitting.

Medication

Medication treating seizures or other neurologic conditions can have side effects. Side effects can include headaches, mood changes and irritability.

Learning differences

When children learn differently, they may try to avoid difficult learning activities. They may use distracting behaviors to do so.

Different Types of Therapy May Help

A therapeutic approach should reflect a child’s abilities. The cause of your child’s behavior may affect their success with an approach.

Age can matter, too. CNF offers a webinar on Age-Appropriate Behavior Strategies.

Children who are nonverbal may also require a particular approach. CNF offers a webinar on Communication Strategies to Improve and Prevent Challenging Behaviors for Minimally Verbal Children.

Some children have challenging behavior requiring an urgent approach. Dr. Joanna Lomas Mevers is a board-certified behavior analyst. She directs the Severe Behavior Program at the Marcus Autism Center, where she works with children with aggressive behaviors. “A lot of parents I’m working with experience PTSD” due to a child’s aggressive behavior, she says.

These behaviors can limit what a child can do. Children with aggressive behaviors may struggle to thrive in:

    • Classrooms
    • Group homes
    • Independent living spaces

Children may need varied approaches to behavior management. What options are out there?

What Is Applied Behavioral Analysis (ABA)?

ABA is a learning and behavior management therapy. It is the go-to behavior therapy in the US. It focuses on two things:

Reinforcing positive behaviors

Decreasing unwanted or harmful behavior

ABA was developed to help children with autism. It was designed to offer these children certain skillsets. It focuses on skills they do not easily develop on their own. ABA is evidence-based. This means scientific studies prove it is effective. However, these studies focus on young children with autism.

ABA is often the only approach offered through early-intervention programs and schools in the US.

But ABA Has Vocal Critics

Intensive ABA therapy has been questioned in recent years. Some argue it is too focused on dissuading behaviors. They say it should focus on developing skills, instead.

Others believe ABA is too focused on making an autistic child appear typical. They think supporting neurodiversity is a better approach.

ABA is not standard in other countries. For example, it is not often used in the United Kingdom. Several other countries are moving away from ABA. They are using more inclusive therapies.

Differences Across ABA Therapy

ABA is not a single approach. It is a set of therapies. Like all therapies, its quality depends on its practitioner.

The field of ABA is growing quickly. Lomas Mevers notes this. She says it is reasonable to have concerns about the quality of ABA currently. “ABA is a very powerful tool,” she says. But it is sometimes used “to change behaviors that maybe shouldn’t be changed.” It can be used “to teach skills that maybe aren’t the most important” ones.

Lomas Mevers has another concern with ABA. It can focus too much on controlled settings. A controlled setting might be a chair in front of a therapist. Performing in a controlled setting is not always important. Instead, she says, real life matters most. Children must be able to respond “spontaneously and naturally in the environment.”

Any therapist working with your child should be:

    • Asking about your priorities and goals for your child
    • Looking at ways to generalize skills beyond a specific task or setting
    • Providing caregiver training, ideally in multiple settings

What Are Alternatives to ABA? 

ABA is supported by much scientific evidence. It has been researched more than other approaches. It also has the longest history. However, there are other options.

Cognitive Behavioral Therapy (CBT)

CBT is a psychosocial therapy. It can be used to halt negative thinking. Lomas Mevers says, “I do not subscribe to the view that ABA is the right thing for every problem.” When appropriate, she uses CBT instead. It can help with secondary issues. Examples include depression and anxiety. However, a child must have communication skills to use CBT.

Speech Therapy and Assistive Augmentative Communication (AAC)

Some children may benefit from intensive speech therapy and/or AAC. Lomas Mevers offers an example. Suppose a child has an iPad taken away. That child may act out violently in frustration. “The problem isn’t that they want the iPad,” she says. It is the violent outburst. Establishing new, healthy communication patterns can help avoid such outbursts.

Neurobehavioral Approach

Eileen Devine explains the neurobehavioral approach. This approach looks at the underlying cause of a behavior. It focuses less on behavior modification. Devine says this approach helps us develop specific tools appropriate to each child. These tools are tailored to a child’s environment and cognitive skills. When we “apply this framework to our unique child,” she says, “symptoms decrease over time.”

More information on the neurobehavioral approach can be found in these resources:

    • Beyond Behaviors: Using Brain Science and Compassion to Understand and Solve Children’s Behavioral Challenges. By Dr. Mona Delahooke. Book.
    • The Explosive Child: A New Approach for Understanding and Parenting Easily Frustrated, Chronically Inflexible Children. By Dr. Ross Greene. Book.

The Takeaway

Ultimately, there is no one-size-fits-all solution to behavior management. ABA is the most common approach in the US. It is most easily accessible. Still, parents may have to fight to access ABA. They may struggle to find time for the intensive therapy sessions.

Newer therapies also have barriers. They can be costly. They may not be covered by insurance. Paying for consulting can add up. These therapies may also require background research. This research can take a lot of time.

However, everyone agrees on one thing. Caregivers are key. They are the ones who make behavior therapy work. This can feel like additional pressure to caregivers. However, making therapies work depends on them seeing themselves as essential.

You are essential behavior-management team-members. You are the expert in your child!

For More Information

You do not have to go it alone. To learn more about some of the behavior therapy techniques discussed here, please visit our education hub on Behavior Management.

For more background about ABA Therapy, and why some parents and advocates find fault with it, read The Controversy Around ABA from the Child Mind Institute.

To learn more about the neurobehavioral approach, read this article that shares a parent’s story and expert advice.

And to get help from someone who has walked in your shoes, please reach out to our free and confidential peer support network.

Thank you to our 2021 Education Partners Acadia, bluebird bio, Greenwich Biosciences, Origin, PTC and UCB.

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