The Meredith Autism Program (MAP) is an early intervention program for preschool-aged autistic children that uses applied behavior analysis (ABA) “for children to reach their fullest potential.” The program opened at Meredith College in 1995. Since that time, the use of ABA to treat autism has faced scrutiny from some members of the autistic community, who describe it as inextricable from its harmful foundations that aimed to “fix” autistic people. The Herald met with various Meredith community members to discuss the evolution, methods and reputation of the program at Meredith.
MAP began in response to community interest, said Crystal Lester, the program’s Associate Director. “It was initially just a series of courses for [Meredith] students, but our then director was getting lots of calls from families in the area asking for services,” she explained. In response, the director received training and returned to Meredith to offer a practicum course in 1998 that enabled students to gain hands-on experience using ABA while minimizing the costs to the caregivers of enrolled clients. Lester stated that what makes MAP unique from other ABA providers in North Carolina is the involvement of undergraduate students and the opportunity they have to become certified in ABA.
As a Meredith student, Lester joined the program in 2000, left in 2006 and returned in 2012. Having worked at MAP for nearly two decades, she said that she has seen a cultural shift. Currently, MAP is not modeled on a single organization or researcher. Lester said that, at one point, MAP was organized around Dr. O. Ivar Lovaas’ 1987 study at UCLA. She added, “I think I was probably a student when we parted ways with UCLA.”
Dr. O. Ivar Lovaas, a pioneer in the field of ABA, is a controversial figure. He used ABA principles in his work with the Feminine Boy Project, a form of gay conversion therapy. About autistic children, Lovaas stated in 1974, “You have a person in the physical sense—they have hair, a nose and a mouth—but they are not people in the psychological sense.” He used electric shocks, slaps and other physical aversives to promote desired, normative behavior in autistic research participants, most of whom were young children. The 1987 research MAP previously cited on their website included the use of aversive reinforcement, and measured success based on how much autistic children became “normal functioning.”
In April of 1998, Kathryn Dove became the director of MAP. Shortly before assuming this role, Dove completed a nine-month internship under the direction of Dr. Lovaas at the Lovaas Institute for Early Intervention. Dove left MAP in the summer of 2020.
The 1987 Dr. Lovaas study is cited on MAP’s website, and Dr. Lovaas is mentioned on a poster framed on the first floor of Ledford Hall. Lester stated that there have been efforts to remove these associations since Dr. Lovaas' views no longer align with MAP's. Lester explained that though Lovaas's methods may have been questionable, "it did give some validation to individuals with autism" as well as a "platform to be able to do things differently."
While many physical punishments like the kind Dr. Lovaas popularized are no longer commonplace, the use of psychological reinforcers is still regularly employed by MAP. Lester stated that these reinforcements are not punitive. Lester acknowledged that MAP uses discrete trial teaching (DTT), a form of operant conditioning, to teach skills to MAP recipients by breaking down learning into small parts and rewarding desired behavior with praise, the removal of uncomfortable stimuli, preferred toys, and other treats. Effective rewards are identified during a preference assessment and the first few weeks of services to learn which items reinforce the child’s behavior.
In the autistic community, the practice of adhering to neurotypical expectations and norms in order to behave in a manner indistinguishable from neurotypical peers is known as masking. Kai Tilley, an autistic Meredith student, spoke of his experiences with ABA outside of MAP. He said, “Phrases like ‘quiet hands’ and ‘normal children don’t do that’ are seared into my memory.” Tilley clarified that “quiet hands'' refers to stimming, or the use of repetitive motions or behaviors to self-regulate, which can “mark out” an autistic person as neurodivergent. In ABA therapy, Tilley developed his main form of stimming (creasing the fabric of his clothes) because “it was quiet enough to not be noticed.” Tilley went on to say, “ABA therapy left me with no substantial assistance regarding challenges I had in my life, and instead taught me how to ‘behave’ so that I wouldn’t be ‘a burden’ on my parents and teachers.”
In the Meredith Autism Program, Lester said that clients are allowed to stim unless it is harmful to the student or impedes the learning process. She also stated that MAP does not promote eye contact for clients unless they show an interest in that activity, and that working on eye contact, as MAP previously noted on their website, was inaccurate.
Lester stated, “As more and more things [about ABA] started to come out, we began to ask, is traditional behavior analysis […] really what we should be doing?” She referenced “pure extinction” as something that began to give them pause and said, “Our whole point is to improve the quality of someone’s life.” Lester clarified that extinction includes planned ignoring, which used to involve “literally turning one’s back” on a child when they displayed an undesirable behavior. This technique is still employed at MAP, but Lester states that more careful assessment now determines when it is appropriate to implement and that they do not completely disengage from the client. Looking back, she recognizes that previous applications of planned ignoring were difficult for families and could have been traumatizing to the child.
Lester said that as MAP employees began reevaluating their approach in the 2000s, “there started to be more [of a] focus on [getting] certifications,” and that, “It wasn’t until I graduated [from Meredith] in 2003 that people started talking about becoming a behavior analyst […] and actually being certified to do the work that we were doing.” Lester credited certification as a means for MAP’s behavior analysts to be better equipped to help autistic clients and to follow an ethical code to “do no harm.”
The certifications that Lester referenced are administered by the Behavior Analyst Certification Board (BACB). A Board Certified Behavior Analyst (BCBA) is the highest level of certification in the field of ABA and requires a graduate-level education in ABA, practical fieldwork hours and a certification exam. The BACB also licenses Registered Behavior Technicians (RBTs). Becoming an RBT requires a high school education, the successful completion of a 40-hour training course and a competency assessment. Meredith students have an opportunity to become an RBT in the third practicum course offered through MAP.
A current Meredith student who wishes to remain anonymous stated that her autistic brother received ABA services from BCBAs and RBTs until 2007. She wrote, “[My mom] says it was so repetitive to the point it was unnatural and that she felt like it was conditioning him to behave neurotypically.” The student attended an overview session for MAP, but decided against participating in the program because of her knowledge about child development and her personal connection to an individual with autism. “I just disagree with the techniques they use to have a child reach milestones,” she said. The student added that her brother “clearly did not enjoy [ABA].”
In Aug. of 2022, MAP’s website stated, “Early, intensive, full-time, highly repetitive teaching is the optimum strategy to change the way a child with autism’s brain processes and acquires information to help them understand how to learn like a typical child would.” Lester said that, “Not all individuals will benefit or make gains from ABA. We have found that to be true in just our small sample size at MAP.” Current Meredith student and MAP worker Lydia Bonecutter stated, “ABA therapy relies a lot on routine and repetition with altering practices [based on] how the client responds.” Lester also said about MAP’s approach to intervention that, “we’ve always been individualized, but now we’re even more individualized.” She added that each treatment plan is tailored to the client based on MAP's intake assessment, ongoing observation, family reports, and when needed, the involvement of medical professionals like occupational and speech therapists.
When asked about harm reduction to clients, Lester responded that MAP employees look for assent from children enrolled in the program and explained that children are not forced to participate in any activity. She explained that assent occurs when a child displays that they are okay with a task. If a child seems uninterested or does not follow directions or prompts, Lester said that they “wait until [the client is] ready.” Lester said that assent is defined differently for each child to account for variations in communication styles.
Grace Devlin, an RBT and student worker at MAP, echoed Lester, “I can see the comfort and excitement for themselves clearly on their facial expressions and body language.” Devlin received ABA therapy as a child and found the practices “[helpful to] my development.” Now she aspires to have a career in the field. She said that MAP is what drew her to attend Meredith.
Devlin is aware of the controversy surrounding ABA and said that the “key to making ABA ethical and valuable [is] listening to those on the spectrum, particularly those traumatized by [ABA].” Devlin stated that one of her non-negotiables was that MAP “asked questions and listened to the autistic community.” Devlin added that she knows that MAP does both of those things because they value her input.
Tilley stated that despite complying with ABA when he received it, and perhaps appearing to give assent, he was still harmed. “Compliance simply means going along with the therapy, and it is far too easy for a child to be manipulated into providing ‘consent.’” He added about his experiences, “I’d never lash out. I’d just sort of retreat into myself and shut down.”
Lester states that she recognizes “the harmful past of ABA.” A statement from MAP said, “Our goal is to disseminate information for how ABA was once implemented in its early days (the 1960s), recognize how offensive it was, and stand behind how the implementation has shifted in order to protect and encourage the uniqueness of each individual in our care.”
In addition to reevaluating the implementation of practices like extinction, Lester says that MAP is updating the language on their website, and changing their logo to an infinity symbol, a mark associated with the neurodivergent community. A statement from MAP said, “We are adopting the gold infinity symbol as a pledge to accept and advocate for the autistic community.”
The program’s previous logo, a blue puzzle piece, sometimes mistakenly linked them with Autism Speaks, said Lester. MAP’s Facebook page shows that the program participated as recently as April of 2020 in Autism Speaks’ #LightItUpBlue campaign. Lester said, “we are not affiliated with them.”
Autism Speaks has been criticized for failing to include the perspectives of autistic people in their leadership and for their portrayals of autistic people as broken and in need of curing. Lester said, “[At MAP], we aren’t fixing or curing anybody.” When asked about the inclusion of autistic individuals on MAP's boards or planning committees, Lester said there were none, but that they had considered creating a volunteer role. A later statement from MAP sent to The Herald said, “MAP wishes to establish a panel of autistic students, parents, and professionals to serve as our sounding board as we navigate our clinical practice. Anyone interested in serving on this panel is welcome to reach out via email.”
Both Tilley and Mallory Kemple, another autistic Meredith student, expressed concerns about the effectiveness and ethics of ABA. A 2020 report released by the United States Department of Defense (DoD) reviewed the outcomes of 3,794 ABA recipients and found that “the number of hours of ABA services rendered did not improve symptom presentation.” Instead, evidence “strongly suggested” that the small improvements made were “not related to ABA services.”
Lester was asked to comment on the DoD report and stated that its use of parent accounts to determine symptom improvement, in conjunction with the lack of caregiver education, may have influenced the informed completion of the parent survey as well as the outcomes of ABA beneficiaries. She agreed with the report’s authors that the lack of parent participation should be investigated.
On April 6, the Herald received a statement from MAP that addressed recent program changes and spoke of their commitment to autism acceptance. Students who read the statement had mixed reactions. Kemple said that she is happy that MAP is dedicated to change, but that they have heard negative things about the program from students enrolled, and hope that MAP “continues to really change and learn.” Tilley described it as “a slap in the face to the autistic community” because “ABA was founded and exists in direct opposition to autism acceptance.”
By Rebecca Simmons, Contributing Writer