When ABA Gets Complicated: Masking, Feeding, Trauma, and Trust

In this episode of Acorns to Oaks, Kristine and Sarah discuss five of the most controversial topics in applied behavior analysis.

They explore whether teaching social skills can become masking, why treatment goals should be tied to the individual’s autonomy, and how ethical care should never be about changing who someone is. They also talk about extinction, forced feeding, planned ignoring, distress, financial incentives, insurance pressures, and what trauma-informed ABA should look like in real life.

This conversation is thoughtful, direct, and rooted in respect for the people and families receiving care. Rather than avoiding the hard questions, Kristine and Sarah talk through them with honesty, clinical experience, and a commitment to doing no harm.

ABA is often discussed in polarized terms. For some families, it has provided support, communication, safety, and meaningful progress. For others, the history and practice of ABA raise serious concerns about compliance, masking, distress, and whether autistic traits are being treated as problems.

This episode does not dismiss those concerns. Instead, Kristine and Sarah talk through them directly. They discuss where criticism has validity, especially around forced compliance, food, distress, and treatment that ignores the individual. They also explain how ethical ABA should be different: centered on autonomy, safety, functional skills, social validity, family support, and the goals of the person receiving care.

The larger question is not simply whether ABA is good or bad. The better question is: what does ethical care actually look like, and how do we make sure the individual is respected at every step?

Acorns to Oaks is presented by Nurture & Nature ABA, providing compassionate ABA therapy and parent support in Valley Village and the San Fernando Valley.

Learn more or schedule a consultation: nurtureandnatureaba.com

Follow Nurture & Nature on Instagram, YouTube, Facebook, and LinkedIn.

This podcast is for educational purposes only and is not a substitute for individualized clinical care.

Transcript

SPEAKER_02 0:07

Hi, you're watching Acorns to Oaks. Thank you so much for listening today and joining us. I'm Christine Dixon, Board Certified Behavior Analyst and Board Certified Advocate of Special Education. And with me today is the phenomenal Sarah Moreau. Hello. Board Certified Behavior Analyst, Registered Nurse Practitioner, Peer Certified, Pivotal Response Treatment Certified. I'm sure there's so many certifications I'm missing for you, Sarah.

SPEAKER_00 0:34

That's okay. I think that's more than enough to cover today.

SPEAKER_02 0:38

Yes.

SPEAKER_00 0:38

But we're going to talk about something very exciting today. Yeah.

SPEAKER_02 0:40

We're coming in hot. That's right. Five most controversial topics in applied behavior analysis. It's in the discourse. And I'm glad, I'm glad there's controversy. We should look at these things and we should talk about them. And we should also actively listen. That's true. Uh when we're talking about them. But topic number one are we teaching meaningful life skills or encouraging masking of autistic traits?

SPEAKER_00 1:08

I believe that we strive to teach life skills that really matter to that individual. Masking.

SPEAKER_02 1:18

I'm masking right now.

SPEAKER_00 1:20

I think like it I think masking is a part of everybody's reality. I agree. I speak very differently with my friends, with my family than I would with a client or someone that I'm working with professionally, a patient. Yeah. Um I think uh it depends also on the setting, you know, what the expectations are in that setting and what your goals are for yourself in that setting.

SPEAKER_02 1:49

Yeah, I don't think we're really working on changing traits. I've never written a treatment goal that's like, we're gonna change this trait about you. Right. It's more like, what do you want to do? What are the steps? How can we break down these tasks? How can we make it more functional, easier?

SPEAKER_00 2:06

Um how can we work on social communication, on topic comments and questions in a social setting? I mean, I don't really see that as masking, but again, I think it goes back to the individual and what they want for themselves. Yes.

SPEAKER_02 2:21

And so one of the things that we sometimes encounter, um, and that we're both certified in peers. Um, and I won't ask you to do the acronym again. But um thank you. You know, friends lead to meaningful and happiness outcomes. And so some of the things that we see, and a lot of times when we enter into um the homes and we're getting to know the clients, there's a little bit of heartbreak. Because one of the stories that we do hear very often is, you know, Tammy wants to have friends so badly, but doesn't. Yeah. And that's tough because when you're dealing with friends and meaningful outcomes of friendship and the science of making friends, um, there is some societal norms and rules. Like you can't get too close to people. That's right. And you can't talk too loudly, and you can't ask them a hundred questions in a row. You can't ask them things that are too personal right away, or tell them uh information that's too personal about yourself.

SPEAKER_00 3:31

Yeah, correcting someone's grammar when they're speaking. People don't like that. So learning these skills, I I don't equate that to masking, I equate that to being able to be successful in a social setting if that's something that you want. Because not everybody does.

SPEAKER_02 3:49

Yeah, and that's okay, you know, but science does tell us that community is a port and part of longevity and also vitality and also happiness outcomes. So that is something we balance with, you know. Um, I think everybody is masking. I do think that uh the autistic community um might be um masking more. Um and I do I do want to hear what they have to say. So if you uh have some insights on masking, I'd love to hear from you. We would um in terms of what that means for you and what reality that is.

SPEAKER_00 4:30

And yeah, and having that understanding, I think, with the people that we work with uh helps us to serve them better. So we appreciate any uh discourse.

SPEAKER_02 4:39

And we serve clients from two to sixty-five. So we have a ton of young adults, we have a ton of teenagers.

SPEAKER_00 4:46

None of them have said to me I'm masking or use that term, or yeah, I have not heard that from any of the clients I've worked with either. Yeah, I know that it is common, a common thing that's said maybe um in conferences and maybe interviews. I I don't know what the origin is behind it, and I'd like to understand it better.

SPEAKER_02 5:08

Yeah, but I do think ABA addresses autonomy. And when I'm doing a treatment, I want to, you know, see your true authentic self. I want to recognize that, I want to be respectful of that, I want to get to know what your identity is for yourself. And I don't know if our treatments ever changed that. I don't think so. I mean, in mental health, uh, people sometimes have compulsions. And um, you know, some of the compulsions we've seen is when extraordinarily upset or frustrated, self-injurious behavior. Yeah. So am I is, you know, is treating self-injurious behavior and um teaching more functional skills like, hey, I'm really pissed off right now, and I don't want to do that, and I need space and you need to get away from me, like that type of functional communication response. Um, in place of, you know, getting so frustrated that you're pulling out your hair, your eyebrows, your eyelashes, hitting your head, slapping yourself, digging your nails in, scratching your face. Since those things are harmful, I don't want individuals to do that. So I'm not sure if that is masking to teach, but I just think it's more, it's more functional expression. It still has uh autonomy and self-respect, but it's not harmful to yourself.

SPEAKER_00 6:32

Yeah, I think that's right. I think um always looking at safety first, always safety first, um, and autonomy. And uh yeah, respecting that we all have different ways of thinking, different ways of expressing ourselves, and trying to guide that in a way that will help that person to reach their own goals.

SPEAKER_02 6:52

Yeah. But are we teaching people to not be themselves? I don't think so. And actually, I really don't think ABA has that sort of power. I don't think so either. I'm in love with our science. I think it's really phenomenal. The potential is enormous. I think how our science works and in the science of motivation and how behavior is shaped by your consequences, right? I think it's happening every day out in real life. And I think it also happens in nature naturally. I need to learn more about what the traits are. If the traits are stimming, um, as we discussed, I think everybody stims. Um, and I don't think there's any harm in stimming whatsoever.

SPEAKER_00 7:34

Yeah, yeah. I don't think so either. As long as it's not something that is physically harmful or dangerous, I think that it's fine. Learning to communicate socially, being able to have a conversation and interact with people. Um, I think that is a skill that does require listening and understanding what people are talking about and uh recognizing when it's your turn to talk and when it's not. I think that that can be really challenging for a lot of the people that we work with, but also we've seen great success with that too. If it's something that they're motivated by and they want to learn. But is that masking of a trait? I I think it's in settings, right?

SPEAKER_02 8:12

So applied behavior analysis means we're taking this science and we're looking at it from a setting lens as to what behaviors are being reinforced and what aren't. So if you're around friends and you're, you know, acting like, you know, you're you're acting like your true authentic self. Um, and that's being accepted, then I don't think, you know, that's a behavior that we need to trait at all. Yeah. But it's a very interesting concept. It came about uh, to my knowledge, like it started becoming really relevant about four years ago. Um and we saw it at that conference in Calaba. Is extinction ethical, especially when it may increase distress in the short term?

SPEAKER_00 9:00

So I know that escape extinction is something that we typically do not use. And escape extinction meaning this is aversive to me, I would like to get away from this task, this food, this stimuli. Oh, for sure.

SPEAKER_02 9:17

Uh and that's that compliance. Yes. That's that that that's a really big critique, but I feel like that critique is somewhat valid.

SPEAKER_00 9:24

I think so too. Yeah. Yeah. I I think that we go out of our way to make sure that we're not causing trauma, which I think can happen through an escape extinction where you're forcing someone to interact with a stimulus that they really don't want to have any interaction with at all.

SPEAKER_02 9:39

Yeah, I think uh I've seen it in real life doing observations at other people's um establishments and clinics. And I have the biggest problem with escape extinction for food. Yes. I do not think it is ethical or right or helpful or functional to shove any food in anyone's mouth that doesn't want to eat that. I've never done that as a behavior analyst. Um, you know, I think more and more behavior analysts need to take an empathetic lens. You need to see how would that feel like to you?

SPEAKER_00 10:12

Yeah. Think of the thing that is most disgusting to you being forced in your mouth.

SPEAKER_02 10:19

And that's 1984. That's coercive. Yeah. If you're doing that, you're doing something wrong. You'll need to stop immediately and you know, get get a mentor.

unknown 10:28

Yeah.

SPEAKER_02 10:28

And go to school.

SPEAKER_00 10:29

Conferences, get training, more training. I believe strongly that that is something that really should not be done in a in-home setting and certainly should never be the first thing that you do to approach um feeding. Oh, yeah. I know it is done inpatient, and sometimes it might be appropriate. I'm not saying that it's not. It's just something that I would not do. Um, and I certainly wouldn't do it in home.

SPEAKER_02 10:56

Yeah. And I think it does, it does produce trauma.

SPEAKER_00 10:58

I think it does. And then you can go from what is a pediatric feeding disorder to uh which is an acute disorder, which can change, to uh avoidant restricted food intake disorder, which is chronic. Um, so we have to be really careful about the things that we do because we don't want to cause trauma that will then cause further problems down the line for the people we're trying to help.

SPEAKER_02 11:18

I mean, not to go back to revisionist history, but do no harm, right? Hippocrates, right? Do no harm. So if you wouldn't want it done to you, don't do it to anybody. Really, you know, it's like, um, but then cost benefit. Um, in hospitals, there is force feeding. It's, you know, I intervenous, right? It's like Yeah.

SPEAKER_00 11:38

And and I I think like, you know, those are other disciplines as well. Yeah. So uh it's not necessarily a behavioral lens that we're looking at uh in a hospital setting.

SPEAKER_02 11:48

You know, so much of social engagement can be reinforced through social interaction. Um, and attention extinction or planned ignoring is highly controversial. Uh, this is where the behavior analysts hypothesize that the behavior is likely to be maintained by social positive reinforcement in the form of attention or a tangible item. Um, tangible extinction, I have really no problem with. You know, if someone is doing a maladaptive behavior that is harmful in order to get a tangible item like the phone, if they're hitting, if they're pushing peers and to get the ball, like and that's a natural consequence as well, right?

SPEAKER_00 12:33

I mean, that all goes away, right? Yeah, yeah. You know, whether you're in an ABA program or not, uh, if you're engaging in those kind of behaviors for access to something that you really don't need to have. Yeah.

SPEAKER_02 12:44

Um it's not a need, it's a want, waiting for a toy at the store, then yeah, I think it's extinction can work, you know. I think so too. When someone says, even for adults, when someone you're engaging socially at a party and someone says some weird comment or backhanded compliment to you, like putting that on ignore is probably a good thing. I think that works. But is extinction ethical when it may increase the distress in the short term? I think that comes back down to the cost-benefit ratio that we really need to look at in terms of uh treatment versus benefit.

SPEAKER_00 13:21

Well, and and I one of the things that we do when we do use an extinction, whether that's tangible or attention, is that we first are providing them with the skill to get the access that they need. Yes. So we're giving them the appropriate language. Um, we're also often encouraging non-contingent reinforcement of attention to reduce that desire to engage in a behavior that's maybe harmful to get that attention. So I think, you know, there are two sides to a coin. You can't have one, you know, or you can't have extinction without having the replacement already.

SPEAKER_02 13:56

Um I have a really interesting story. I'd like to get your take on it. And it actually happened like roughly 10 years ago. So it's a nice timepiece, but had a little boy uh refuse to get out of the car when his parents, when they got home, refused for hours to get out of the car. Parents would spend excessive amounts of time trying to get him out. He would be, he would become physical. He did not want to get out of the car. Um, I saw it. I looked at the antecedents, the behavior, the consequences. I saw it several times. Uh, you know, there was a lot of parent engagement with the child, and that's powerful for the child. Like, you know, when I can make the whole room stop and look at me, that's really powerful for a child and even some adults. Yes. But we did do attention extinction and we did it very safely. We had safety guards in place. We had uh we were in like 15 feet of the child. We were looking out the window, he couldn't see us. We ignored the behavior, we had the car door open. Uh, it was warm that day, so we put water in there, and we just said, Okay, we're going inside. Bye, see you later. And that child sat in that car for over an hour. Oh, wow. In like 80-degree California sun. Wow. Before he came up to the door and came in, and then it was like, Oh, good to see you. But we did do planned ignoring and it worked really well. He never did it again. Yeah. We waited him out, he never did it again. So I do think that is can be powerful, but you gotta have safeguards in place. Yeah.

SPEAKER_00 15:37

It's gotta be the right um Yeah, because people can get hurt, you know, if if you don't have that.

SPEAKER_02 15:44

And it can produce trauma. So, an instance, I've never done this, but if a child was in desperate need of help or something like that, and you're like, oh, do it yourself, and then I'm gonna put this on extinction, planned ignoring. I think that's unethical. Yeah. Um, ignoring signs of distress are unethical. I don't think you should ignore it. Um, should you go through the burst? It depends what that looks like. It depends. Yeah, yeah. That's why it's good to have a behavior analyst in the moment. Like when I do something like an extinction procedure, I always say, we're gonna be there to do the heavy lifting because it is heavy lifting. You have to make real-world treatment decisions in the moment, gauging, do I have a scent? You know, does the ABA industry prioritize client outcomes over financial incentives? I don't think so. We don't make that much money.

SPEAKER_00 16:39

Honestly, I mean, do we prioritize outcomes over incentives? Is that did I hear it right?

SPEAKER_02 16:46

Yeah, or I guess what they're trying to say is financial incentives over um client outcomes. No, no, in our private practice, we want to work with the best people, we hire the most experienced, you know, it's about drawing great, phenomenal people to us and keeping them. So and there are a lot of ways to make money. Oh, yeah.

SPEAKER_00 17:05

This is not really. No yachts here.

SPEAKER_02 17:25

Yeah, no yachts here. Yeah. And then, you know, at Nurtrue Nature, we invest a lot in the team. And I we're Denise and I are always trying to put things back in place. Like we have the Catles coming to do um a training on AI, the founders of PRT. Um, and then we I like to buy lots of toys and incentives and motivation and make a ton of visuals and have sensory toys. And so And it's really about enriching lives.

SPEAKER_00 17:52

It really is. It's really about staff, yeah, you know, clients, families, yeah, across the board.

SPEAKER_02 17:58

Yeah.

SPEAKER_00 17:58

That's what's really rewarding.

SPEAKER_02 18:00

I think when the board of directors is two behavior analysts with, you know, zero business education, except for you know, street education and business. Um, no, it's we don't even track those KPIs. Like I think someone we were walking, we went to APBA and we were walking down the streets, and a colleague came up to us and and uh lovely, lovely person, uh, very entertaining, and was like, How are you? And you know, we build 950,000 clinical hours this year. And I was like, we don't even track how many clinical hours we bill in a year, like that's not important to us, you know. And then I was like, you know, I had no idea the number because I never even thought in the framework of that.

SPEAKER_00 18:50

I do wonder about companies that are so huge. Oh, yeah, that have, you know, they have places all over the country. How can you possibly know what's going on if you're that big? Um so I don't think that's true for our company. I think we strive to have excellent outcomes. Um, but I do wonder industry-wide, if there are maybe some that are maybe a little too big to really be impacting each individual in the way that's like.

SPEAKER_02 19:23

So when you have two behavior analysts making the decision with in shared governance, which we do try to implement as much as possible, um, I think that's very different than a board of directors, a venture capitalist trying to pull. And we saw that with, you know, trying to pull huge financial gains as leveraging right equity and stakes in companies. Like, I don't, I don't think children should be a part of that. But I think healthcare in general, the big business, big pharma of healthcare, these contingencies, I believe, this is my opinion, um, may not be supporting the best health, meaning that the science is out there, the treatment is out there, but we're not getting the best care because of financial incentives. I agree with you because ABA is part of the medical model. I guess I have to kind of say, yes, at times, I mean, definitely the financial incentives for insurance companies. I mean, that's like, yeah, right, that can be a real hardship wrestling those authorizations. And now it's getting harder and harder and meeting medical necessity and the amount of contingencies on us as practitioners is truly intensified over the last three years. But do we as an industry prioritize um financial incentives over client outcomes? No. We we actually have uh very important values in our science of social validity and and and doing no harm and making sure that we're improving the lives of others. Absolutely. Last question What does truly ethical trauma-informed ABA look like?

SPEAKER_00 20:59

I think it starts with the individual because trauma looks different for me and for you and for everyone that we meet, uh, based on their history, based on what they have experienced. So I think you know, everything we've talked about keeps coming back to the individual, the goals they have for themselves, um, and taking into account what experiences they may have had that may affect the way that we approach a behavior. I think about escape extinction again. Yes, you know, if you have a client that's experienced abuse, for example, or that has been neglected, you're probably not going to do plant ignoring, you know, for someone who's experienced a lot of neglect.

SPEAKER_03 21:42

Yeah.

SPEAKER_00 21:42

Um, if you've had someone who has had physical abuse, you're probably not going to do any physical prompting, which we don't unless there's a safety issue, right? So I think I think trauma informed care in ABA really comes back to looking at the individual and seeing what's right for them.

SPEAKER_02 22:00

And I can see it in my own life with like, I hate going to the dentist because for me it's torture. And, you know, I had bad experiences as a child where it's like, she's a bleeder, you know, like, you know, so like there's trauma there for me. Yeah. Um, in California, we have the ACEs aware certification that's actually free to all clinicians where you can get certified in trauma-informed care, which we I have done. Um, have you done that as well? Yeah. And I think that's really important because it talks about real contingencies that affect real health outcomes. Like, you know, why aren't they taking their meds? Yeah. Why aren't they eating why do they still eat these foods when they know it's harming them? Why do they not prioritize sleep? Like, why do and so when you look at those contingencies, you really have to look at is there past trauma?

SPEAKER_00 22:56

Absolutely. And ACES has actually grown. It used to just be uh looking at things that have happened in the past that will adversely affect you. Now they also have identified protective factors. Um there's an image of a seesaw. So you'll have like on one side, you know, um say abandonment or abuse, but then on the other side, you have social support and you have um, you know, health or or emphasis on healthy activities, right? So these things can kind of balance themselves out, which I think is really helpful to look at what we should do then when we have this ACES score and we see that this person has had an experience of trauma in the past, and what can we do to then tailor our approach uh to help them be most successful?

SPEAKER_02 23:42

And I think those that's one of the questions that you as a behavior analyst really wanted to explore becoming a nurse practitioner was what are the contingencies or why do people do things that are against their health, right? Like how is that? But that really comes from past histories of reinforcement.

SPEAKER_00 24:03

Yeah, you know, the environment, the fire contingencies in the environment. Um, yeah, that's something that I'm I'm hoping as I expand into primary care, I will be able to identify the individual contingencies that are affecting people's behavior to then also affect their health, um, to meet their own goals and to do the things that they want to do.

SPEAKER_02 24:25

Yeah. Because let's be really real, entering into any sort of treatment, whether it's ABA or it's any type of treatment, is scary. It's scary. And you sometimes enter into it because you have real problems, health problems, or real fears. Um, anytime we're doing early intervention with parents, you know, Denise and I always say they're they're precious families because you have to hold them with great respect. Um, you have to actively listen. And a lot of times, you know, when a parent gets that their child has a diagnosis, they often say to us, It's the worst day of my life.

SPEAKER_00 25:09

Yeah.

SPEAKER_02 25:09

You know, and they need to be supported and they need hope, you know. And I think going through some huge health wars in my family, you know, that positivity, that hope, uh, that can do a lot of good when you bring in a lot of good vibes and positivity and it's gonna be great and it, you know, we're gonna make progress. Yeah. And that's one of the things that ABA does extraordinarily well. I would agree with that.

SPEAKER_00 25:36

I I think that the uh primary care could learn a lot from ABA in that way, because I think when you have 15 minutes with a patient, because insurance is dictated you need to see 30 in a day. Um there are things that just get missed, that get dropped. You you really don't have the time necessarily to invest. And I think that um you get a lot better outcomes and you get a lot better care. If we could really just address that person with everything they bring with them, um, everything from home. Why are we engaging these behaviors? What is this doing for us? What could we do to make a change? Um I'm hopeful that as we move forward into the future, some of this research is gonna pan out and some change.

SPEAKER_02 26:25

Yeah. And hopefully we get some serious reform on the insurance companies that are demanding all these unethical, in my opinion, I will state this is my opinion, um, unethical, unrealistic treatment models.

SPEAKER_00 26:41

And then don't blame our science, you know, like I and I think that the insurance companies have a contingency where the bottom line is the most important thing, and not care, not the healthcare outcome. And that is um completely uh in conflict with what we want as a society to be healthy and to be well. So let's work on that, huh? Yeah, let's work on these contingencies.

SPEAKER_02 27:06

But our science has data, and that makes a big difference because you can show systemic progress, and that progress builds hope and potentiality of what can be possible. And so, you know, those baby steps to greatness with our data and being able to show that we're making progress, even at the incremental level, I think is so helpful to any person wanting to do change. Yeah. Because, you know, sometimes, you know, when you're running, you gotta walk around the block first before you can run a marathon. And, you know, I think the data helps that. Yeah.

SPEAKER_00 27:45

Each step. Each step is something to celebrate.

SPEAKER_02 27:47

Yeah. And observable and measurable things, I I think are also very important because then we can track the smallest change and provide hope based on that.

SPEAKER_01 27:59

So five hot topics in AVA. So hot, so controversial. We're bringing up.

SPEAKER_02 28:07

But thanks so much for joining us on Acorns to Oaks. I'm Christine Dixon.

SPEAKER_00 28:12

I'm Sarah Moreau, and we really want to engage with you. So if you have some thoughts you want to share, please comment, please subscribe, please just reach out and let's have a discussion. Like us or don't.

SPEAKER_02 28:23

Yeah, that's okay too. We believe in autonomy.