Behavioural early interventions (ABA, ESDM): evidence and criticism

What is meant

ABA stands for “applied behaviour analysis”, a collective term for methods that build behaviour through reinforcement. In the guideline, two types of programme based on it appear: EIBI (Early Intensive Behavioral Intervention) as very structured one-to-one support following the “discrete trial format” (small-step exercises, directive, by trained therapists), and ESDM, which additionally stresses playful, reciprocal interaction and guidance of the parents. ^{[4, Ch. C.4.2, p. 93 f.]} A further classification of the therapy landscape: Autism-specific therapy and support.

What the 2021 guideline recommended

For toddlers and preschool children, regardless of developmental age and cognitive skills, the guideline recommended (grade of recommendation A, evidence level 2) a therapy that starts early, at the latest from two years or directly after the diagnosis. It should be individualised, development-oriented and behaviour-therapy-based, work with scientifically tested manuals and guide the parents in supportive parent–child interaction. As benchmarks, it named a duration of at least one year and at least two hours per week, plus practice by the parents in everyday life. ^{[4, Rec. 10]} Essential building blocks included: a standardised assessment at the start, attention to the child’s interests and needs (“over- or under-demand should be avoided”), training in joint attention, imitation and play, reinforcement of a natural, preferably social kind in situations close to everyday life. ^{[4, Rec. 10]} It did not regard parent training alone without the child as sufficient. ^{[4, Rec. 10]}

At the same time, it stated that the diagnosis does not per se mean that ongoing therapy is needed and that every therapy should have clear, concrete goals and a limited period, in which the family also takes part. ^{[4, Rec. 1]} Methods involving direct punishment or coercive measures should never be used. ^{[4, Rec. 30]} More on goals and duration: Early intervention for autism.

EIBI: what studies showed

The guideline summarised a Cochrane review (updated 2018) that included four non-randomised comparison studies and one randomised trial on EIBI. All had a high risk of bias, because the results were mostly not collected by an independent, blinded party. For social interaction and communication there was no effect; for receptive and expressive language, improvements were seen. For adaptive behaviour (daily-living skills), an effect was seen in the unblinded measurements, not in the only randomised trial. The intelligence test score was higher directly after therapy; this difference was not stable at follow-up in two studies. ^{[4, Ch. C.4.2, p. 93 f.]} Elsewhere, the guideline referred to analyses according to which good behaviour-therapy training and supervision of the therapists increased the effects; the samples were in part very small. ^{[4, Ch. C.3.2]}

ESDM and other programmes

On ESDM, the guideline named a randomised trial with 48 children aged 18 to 30 months at the start of therapy (24 per group, some drop-outs), with about 20 hours of therapy per week over two years plus parent guidance. After one and two years, a greater rise in the developmental/intelligence score was seen, and after two years better language scores and less deterioration of daily-living skills. The severity of autism features (ADOS) and repetitive behaviour did not differ. The guideline rated the risk of bias as “unclear”; effect sizes were not given. ^{[4, Ch. C.4.2, p. 94 f.]} For the LEAP programme in inclusive nursery (177 children in 28 groups compared with 117 children in 23 groups), it reported improvements in autism features, intelligence score and language, likewise with unclear risk of bias. ^{[4, Ch. C.4.2, p. 95 f.]}

As not (sufficiently) effective for social interaction, the guideline rated in randomised trials, among others, “pure structuring measures” without targeted training, pure parent training without the child, Hanen “More Than Words”, improvisation-based music therapy, sensory integration therapy, horse-riding therapy and facilitated communication. There was a dissenting vote on this from the Deutsche Musiktherapeutische Gesellschaft. ^{[4, Rec. 12]}

Criticism from the perspective of those affected

In a small British interview study, ten adults on the autism spectrum reported on experiences with ABA in childhood; the study mostly described adverse long-term consequences, and the participants were recruited via social media and organisations. ^[3] A further small study with adults who as children received therapies to “fix” repetitive behaviours described both positive and negative interpretations. ^[2] Such studies are not representative: those who come forward often have particularly strong experiences, and earlier therapies are hard to compare with today’s programmes, which according to the guideline stress natural reinforcement, the child’s interests and avoiding over-demand. ^{[4, Rec. 10]} Precisely for this reason it is useful to ask concretely what happens in a programme.

What else you should know

• Questions before starting: What are the concrete goals? Who carries out the exercises? How is reinforcement used, how are refusal or stress in the child dealt with? How is success measured, and when is it reviewed? These are suggestions from the editorial team that follow the guideline on goals and monitoring. ^{[4, Rec. 1, Ch. C.1]}
• If your child is visibly suffering: Talk to them and stop before you continue. Note: this is an assessment by the editorial team. According to the guideline, punishment and coercion are never appropriate. ^{[4, Rec. 30]}
• Costs and responsibility: Financing autism therapy: who pays, who is responsible?.
• As an adult with your own experience: Your experience counts. The studies named here only show a section.

Sources and literature

1. DGKJP. Aktuelle Leitlinien (Einträge 028-018 „Gültig bis 04.04.2021“ und 028-047 „Gültig bis 23.03.2026“). https://www.dgkjp.de/wissen/aktuelle-leitlinien/ – Professional society (website in German)
2. McCormack L, Wong SW, Campbell LE. ‘If I don’t Do It, I’m Out of Rhythm and I Can’t Focus As Well’: Positive and Negative Adult Interpretations of Therapies Aimed at ‘Fixing’ Their Restricted and Repetitive Behaviours in Childhood. J Autism Dev Disord 2023;53(9):3435–3448. https://doi.org/10.1007/s10803-022-05644-6 – Qualitative study
3. McGill O, Robinson A. ‘Recalling hidden harms’: autistic experiences of childhood applied behavioural analysis (ABA). Advances in Autism 2020;7(4):269–282. https://doi.org/10.1108/AIA-04-2020-0025 – Qualitative study (10 Teilnehmende)
4. DGKJP, DGPPN et al. Autismus-Spektrum-Störungen im Kindes-, Jugend- und Erwachsenenalter. Teil 2: Therapie. S3-Leitlinie, AWMF-Reg.-Nr. 028-047, Stand Text 02.05.2021. – Guideline (in German); expired on 23 March 2026