Can ABA be Trauma-Informed and Effective?

According to much recent research, individuals with Intellectual and Developmental Disabilities (IDD) face a greater risk than neurotypical people of experiencing adverse reactions to adverse events. There are a number of reasons for this, not the least of which is the general deficit in adaptive living skills that make this population more reliant on others for protection and care. Due to this need for care, this population is exposed to many caregivers which increases risk of exposure to abuse, neglect and exploitation (ANE). Not only might caregivers abuse or abuse for nefarious reasons, but it can also happen from a place of “help.” Caregivers may put hands-on to block self-injurious behavior (SIB), encourage attendance to event to meet social goals, or use medication to “relieve” symptoms. This population is given medications with side effects of pain, lethargy, involuntary movement, hallucinations, dry mouth, and other serious physical side effects. When our folks engage in behaviors such as aggression, self-injury, and property destruction, it makes “caring” for them stressful. Increased stress for caregivers has also been suggested as a cause of higher likelihood of ANE. And, unfortunately, many of our folks have communication difficulties that make it difficult or impossible to report on abuse/neglect in a timely manner, if at all. With these considerations, there is a movement to assume trauma.

               Applied Behavior Analysis (ABA) uses methods derived from scientifically established principles of behavior to establish interventions in educational and treatment programs for individuals with the need for behavior change. Historically, ABA has, although being very person-centered, not focused on trauma. However, there is a current movement amongst behavior analysts to embrace this assume trauma. This assumption suggests behavior analysts should, during assessment and when determining treatment, consider the (potential) trauma history of the person. This sounds amazing and only the callous person would say this won’t work. I am not that person. However, I am going to discuss, from my experience and expertise, whether this assumption is compatible with ABA.

               Let’s consider a 22-year-old man with IDD and severe SIB. He has taught himself or learned to self-restrain by putting his arms under his shirt and wrapping his arms tightly around his chest. However, this highly limits his ability to function which, therefore, limits his ability to meet his goals in his home (preparing simple meals, putting away laundry, personal hygiene). When told to engage in his goal work, this man complies but then engages in significant self-injury such as slapping himself in the head and biting his hands. The Board-Certified Behavior Analyst (BCBA), highly trained in ABA, comes in and observes the situation. They notice when a demand is placed to engage in hygiene or a chore, the person engages in SIB. Obviously, they are doing it to escape the demands. The first thing they train staff is “don’t let them escape as that will reinforce the behavior.’ However, had the BCBA known that this same person learned to wrap themselves up when feeling internal tics to self-injury, had they known that a prior caregiver used physical compliance techniques, had they considered that this person burnt their hand when using the microwave 2 years ago…they may (hopefully) would have also considered accepting self-wrapping as not only a coping mechanism but also as a form of communication asking for time and space. In this view, SIB would not be a “maladaptive” behavior but an ADAPTIVE behavior that he has learned to save himself from internal feelings, violence, and pain.

               But what is the answer then? We do not want people to injure themselves or others. Nor do we want people to spend their lives isolated and self-restrained. So, can ABA be trauma-informed AND effective? I believe it can! ABA is a data-driven science but often relies solely on quantitative (numerical) data. What if we combined that very important data with more qualitative (narrative) data? I believe analysts have an obligation to pull all relevant data together before beginning any assessment or work directly with the person. This means reading all the documentation, even if it may seem irrelevant. Putting together a timeline that shows changes and experience. Interviewing whoever may have information and then interviewing, to whatever extent possible, the person. BCBAs need to identify those events that may contribute to what we are currently seeing and identifying if any assessment or treatment may have paradoxical effect based on that history. And then, questioning the literature and choosing interventions that are person-centered, traum-informed and effective.]

               Let’s go back to our young man. What if instead if focusing on this “escape-maintained behavior” and forcing compliance, the analyst trained the staff to use Skill-Based Treatment (SBT)? Meet the person where they are, respect their communication the first time and every time, and then teach begin training following the consumers lead. They teach him to sign or say, “my way” and when staff demand, he can delay and not have to remove his self-restraint. He feels accepted and safe. Eventually, maybe the staff can say “my way,” and he complies. But he only does so because he knows if those internal triggers tell him, he can immediately self-restrain and feel safe. Or if a cue is missed and he needs to rely on SIB, the staff know to back off (keeping him safe of course) and remind him that he has the power in this relationship. That, I believe, is the real essence of trauma-informed ABA treatment. Moving from compliance to acceptance and understanding that the function of behavior is never as evident as it seems.

(Brenner et al., 2018; Daveney et al., 2019; Hanley et al., 2014; Haruvi-Lamdan et al., 2018; Kildahl et al., 2019; Mpofu et al., 2020; Thornberry & Olsen, 2005)