Ethical Considerations When Asked to Collaborate with ABA “Therapists.”

Allyson Goodwyn-Craine M.S. CCC-SLP

I recently attended a seminar given by Vincent Carbonne, a proponent of “verbal behavior” training. What he described as the most effective and efficient means of correcting speech disorders in children with autism looked to me to be very similar to articulation approaches used since the 1970’s (complete with food rewards). Indeed, the Skinnerian assertions so passionately presented to the crowd, as “leading edge” were notions I studied in Behavior Mod. 101. The speaker guided the audience through a generic articulation assessment to determine whether or not to teach specific speech sounds based solely on developmental articulation models. He went on to suggest that if the ABA “therapist” did not feel speech was a good option they should prescribe an augmentative communication system, he preferred sign language. My heart sank.

I attended this conference by invitation from an Applied Behavior Analyst who had recently asked for me to assess a child with autism she described as “apraxic”. Imagine my surprise as the analyst presented data from criterion based and standardized speech and language protocols, a developmental articulation analysis and copious data reflecting the efforts of her ABA team to “correct speech sounds”. In this particular case they had also implemented a “fluency program” to address what was initially perceived as stuttering but was now thought to be “apraxia”. The analyst was hoping I could assess the client, offer a differential diagnosis, outline a treatment program for her team to follow and be on my way.

I looked around the room filled with dedicated and concerned parents seeking the best and most immediate treatment for their autistic children. Parents call my practice almost daily seeking services, or the services of my colleagues, only to be placed on ridiculously long waiting lists. These battle-weary and anxious parents are simply looking for someone to help, but who is available to go toe to toe with their child numerous hours a week? Parents have few options and ABA “therapists” fill that void.

What is ABA?

Applied Behavioral Analysis (ABA) is a teaching strategy used by a wide range of disciplines including special education teachers, psychologists, behaviorists and speech-language pathologists using a classic stimulus/response/reinforcement format. Encompassed under the ABA umbrella is a behavioral approach to teach speech and language referred to as “verbal behavior”. Sequential training targets are established using a variety of resources such as “The ME book” by Ivar Lovaas. Nationwide, parents of children with autism rally around ABA services, many with the hope of a cure. This belief is based upon the book “Let Me Hear Your Voice” by Catherine Maurice in which the parent outlines procedures used to cure her child of autism.

Although many ABA practitioners in the field are skilled, the area of ABA is loosely structured and poorly regulated. Board certification has been slow to catch on and essentially anyone can hang a shingle proclaiming expertise in Applied Behavioral Analysis. In the State of Oregon there are only two “board certified” analysts (BCABA). Parents pay between $75-$150 per hour for the services of the analyst who provides diagnostic services and designs treatment plans.

The Behavioral Analyst (or any person) claiming expertise in this area typically employs (or requests families employ) ABA “therapists” to implement a variety of training programs including speech correction and language instruction at a rate of $10-$20 per hour. While these “therapists” often have a B.S. degree the prime “therapist” employee is a student enrolled in Speech and Hearing Sciences programs.

Board certification and graduate programs in Applied Behavioral Analysis do not include coursework in normal language development, language disorders, articulation/phonological analysis, stuttering disorders, oral motor speech disorders or augmentative communication. One behavioral analyst I work with states that the majority of her knowledge (which is admirable) comes from purchasing materials and resources from our field and her own continuing education experiences. When asked why speech and language coursework is not included in their training programs given their interest in creating intervention programs in these areas she answered, “We view speech and language exclusively as a behavior. We are perfectly qualified to correct behaviors.”

The Problem for Parents

Many parents of children with autism are disenchanted with the services provided by speech-language pathologists when we focus exclusively on social-pragmatic interventions. Problems arose because significant budget constraints leading to high caseloads in the public education system and with limited number of treatment hours available with private practitioners most speech-language pathologists can no longer concentrate on all core areas of language development focusing on content AND form AND use. As a result, many concentrate heavily on USE, as it is the most challenging issue for children with autism. They often neglect content and form. Parents often seek other service providers to fill in the gaps. Enter ABA “therapists” who focus heavily on content AND form (speech).

Legal Issues

There is significant debate over the effectiveness of ABA/verbal behavior approaches when compared to social-pragmatic language interventions. While I have seen children with autism benefit from a combination of both, legal and ethical difficulties arise when asked to collaborate with ABA “therapists”.
For example, often ABA “therapists” create and implement oral motor and articulation programs without clinical training in articulation/phonology or motor speech disorders nor are they under the direction and supervision of a licensed speech-language pathologist.

Despite overwhelming requests, I do not enter into a consultant service delivery model with parents of children with autism and ABA “therapists.” I do, however, work alongside ABA teams and have been challenged on many occasions to revisit many of the “old” language instruction philosophies. Instead of engaging in debates, we simply acknowledge our philosophical differences and respectfully move forward. Parents find it comical at times when I state the child is using generative language while the ABA team members are asking, “who taught the child that new word?”

The ABA teams have been willing to move slowly as I navigate my way through several ethical and legal issues. Although team members have been eager to learn treatment strategies to implement during their training sessions they have respected my refusal to provide such training because they are not certified as Speech-Language Pathology Assistants. To be honest, this is very frustrating for me when I observe the skills of particularly talented ABA “therapists.”

Oregon law, however, clearly prohibits assisting or permitting any person to practice speech-language pathology without a license. In the state of Washington, where they have no SLP licensing requirements, many Speech-Language Pathologists engage in transdisciplinary practices with ABA “therapists” based on the ASHA guidelines which state that: “Support services may be delegated to persons who are neither certified nor in the certification process only when a certificate holder provides appropriate supervision.” (Principle of Ethics II, D. ASHA). In the State of Oregon, however, a new statute stipulates that a person must be certified as a Speech-Language Pathology Assistant and provided direct supervision by a licensed speech-language pathologist when engaged in treatment.

In the Real World
I routinely give “speech homework” to the parents of children with autism on my caseload. Several of my colleagues, however, routinely delegate these types of activities to ABA “therapists” when requested by the parents. At first blush, this seems to be a reasonable approach until one considers the potential ethical and legal implications. This practice could be interpreted as a violation because the “therapist” is being paid to work with the child. Unlike a nanny or other paid caregiver, ABA “therapists” are being paid for is to correct speech. Therefore the speech-language pathologist would technically be in violation of state law and on shaky ground with regard to ASHA standards.

Despite the initial requests that I diagnosis, create a treatment plan and promptly exit, the ABA teams have understood my obligation to treat the children directly. However, my hands are tied both ethically and legally when trying to coordinate treatment efforts with the ABA teams since I cannot suggest modifications of ABA verbal behavior (speech and language programs) because it is unclear as to whether these service providers exceed an appropriate scope of practice according to Oregon statutes. Given strict legal definitions some may argue that ABA teams members are practicing Speech-Language Pathology without a license. For this reason many Speech-Language Pathologists choose not to enter into a co-treatment relationship with ABA “therapist” as we routinely do with physical, occupational therapists, and special education teachers for fear this practice be interpreted as “unprofessional conduct.”

More Questions than Answers

These issues raise more questions than answers. Perhaps the most important is: how do these legal and ethical constraints impact the families of children with autism seeking collaborative services? Is collaboration between Speech-Language Pathologists, Behavior Analysts and ABA “Therapists” possible? There is hope. Oregon law clearly prohibits assisting or permitting any person to practice speech-language pathology without a license.

The Oregon Speech Language Association Board of Directors has requested that these issues be brought to the attention of the Ethics Committee, Oregon Speech-Language Pathology Health Related Services Licensing Board and the Ethics Director of the American Speech-Language Hearing Association. All readers are invited to provide feedback, concerns and questions to be reviewed by members of these various boards. Parents of children with autism, SLP colleagues, ABA team members and other interested parties are encouraged to participate in this discussion. Send your response to the email address below.

Allyson Goodwyn-Craine is president elect of the Oregon Speech-Language Hearing Association and a private practitioner in Portland, Oregon. Contact Allyson at Goodwyn464@aol.com.