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Developmental-behavioral pediatrician Ronald L. Lindsay discusses his article, “A pediatrician’s reckoning with behavior therapy.” He shares his profound professional and personal pivot, moving from a decades-long focus on measurable goals to understanding the deep trauma and harm caused by applied behavior analysis (ABA). Ronald explains why he now supports the #BanABA initiative, detailing how the therapy often prioritizes compliance over communication and normalization over neurodiversity, particularly for nonspeaking autistic individuals. He calls for a shift away from coercive behavioral interventions, which were driven by insurance mandates, toward dignity-centered alternatives like DIR/Floortime and robust AAC support. Learn why this pediatrician is unbuilding his legacy to advocate for autistic voices and ethical, trauma-informed care.

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Transcript

Kevin Pho: Hi. Welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome Ronald L. Lindsay. He is a developmental-behavioral pediatrician. Today’s KevinMD article is “A pediatrician’s reckoning with behavior therapy.” Ronald, welcome to the show.

Ronald L. Lindsay: Thank you for having me.

Kevin Pho: All right. We will talk about your article in a little bit, but let’s first briefly share your story and journey.

Ronald L. Lindsay: My story is that I have been a developmental-behavioral pediatrician for approximately 30 years. I just recently retired in Jacksonville, Florida, but I haven’t stopped my advocacy for children with developmental disabilities or autism.

Kevin Pho: For those who aren’t familiar with ABA, applied behavior analysis, how often is that being used today in the United States?

Ronald L. Lindsay: It is used constantly because basically pediatricians, including the 700 remaining developmental pediatricians, are too stupid to understand that there are no measurable outcome measures.

Unlike the risperidone drug studies that were working on reducing disruptive behavior in children with autism, where we had two measures: an improvement by 25 percent in the Aberrant Behavior Checklist irritability subscale, and Clinical Global Impressions (very much better or much better) as ascertained by a psychologist. You had to have two thumbs up, Siskel and Ebert, in order to be determined to be a responder. In that study, we had a 70 percent response rate and a 16 percent response rate to the placebo.

ABA does not have any measurable goals to achieve. Because of that, there is no way to tell whether or not it is working. The only randomized trial was in 2000. It involved 15 children, half of whom had autism and half of whom had pervasive developmental disorder not otherwise specified, a different condition.

They went through ABA. These children, using the terminology at the time, were mildly or moderately cognitively impaired. The average IQ was 50. As a result of ABA therapy, their average IQ raised up to 55. I am sorry, but that is like using a dimmer switch. Because you are supposed to be at an IQ of a hundred plus or minus 15 percent, these kids were three standard deviations below the average IQ for an American child. Since they were three years old, they were functioning like 15-month-olds. At the end of the study, they were functioning like 16-month-olds. I don’t know whether or not it was ABA or if it was actually just time that was the primary factor.

Kevin Pho: And today, what are some of the typical indications where ABA is used or prescribed or referred to by pediatricians?

Ronald L. Lindsay: Primarily for the treatment of autism. There are other therapies that are much more rigorously studied and are accepted. For example, DIR/Floortime for preschoolers. There are also the LEAP and TEACCH programs that were developed at the University of North Carolina for school-age children.

But the problem is ABA got its start, and it is following after a Life magazine article in which basically they were using aversive reinforcement to get kids to comply.

Kevin Pho: Despite the accusations against ABA, it is still being used. So what are some of the arguments to keep using it? Despite everything that you said.

Ronald L. Lindsay: There are no arguments. Matter of fact, the state of Idaho just banned ABA as a therapy to be paid for by Medicaid because there is no evidence of efficacy. Right now, there is a court case in Wake County, North Carolina looking at ABA, and at this point in time, there is an injunction placed on ABA payments for ABA therapy. It doesn’t work.

So, you look for the alternatives: DIR/Floortime and AAC. AAC is adaptive communication. That is where people are using devices, electronic devices, to allow a child to push a button (yes or no, or A and B) to answer the question: “Do you want gummy bears or would you like teddy bear snacks?” A child can sometimes point to the desired object, but other times they have to press a button because they are nonverbal.

Kevin Pho: And these alternatives, how often are they being used in this context?

Ronald L. Lindsay: Not as widely as the evidence shows that they are superior. My feeling is very simple. I believe in measurable goals. If a therapy works, you keep on using the therapy and keep on upping the goals. It is basically what I have to do every time I have surgery on my knees or my feet. I have to go and achieve goals. I have to do a certain number of exercises, and if I cannot make progress, then Medicare will no longer pay for that particular therapy. That is the problem that we have with developmental pediatricians because they haven’t really looked into the founding documents from 60 years ago, looking at the studies that proposed ABA as a therapy.

Kevin Pho: So right now there is a “Ban ABA” initiative. Tell us more about the roots of that. Who is organizing that and what does it hope to achieve?

Ronald L. Lindsay: There is an organization of people with autism who are high-functioning, as well as parents of children with autism. And they see that the use of aversive reinforcement is basically akin to torture. Therefore, they want to see the practice banned in the United States. Now internationally, the Association for Behavior Analysis International in November 2022 condemned aversive electric shocks as a reinforcer for ABA. But the American association, which is the Behavior Analyst Certification Board, still allows for punishment as opposed to reinforcement.

So when electric shocks are being used, we have to ask: “Only after less intrusive methods fail.” What does that really mean in practice? In practice, that means inducing electric shocks onto the feet of children who, by their nature of having autism, are very, very sensitive to sensory input. Is that little electric shock a tickle, or is it a full-blown taser attack? I don’t know. I am not autistic, and I have not been hit with one of those electric shocks or a taser, nor do I desire to basically have that happen. The only time I have gotten into an electric shock is when I made a mistake and touched a live wire while trying to fix it.

Kevin Pho: I think from my understanding, does the modern ABA still use punishment-based therapies? Like, isn’t it more regulated now and nothing like what ABA was originally designed for?

Ronald L. Lindsay: It is currently regulated by true believers of ABA. There is no independent member on the board that regulates ABA therapy. In other words, they are all ABA behavior therapists. None of them are physicians. None of them are psychiatrists. None of them are advocates of non-ABA therapies. So the problem is that the American Psychiatric Association basically has packed the regulatory body with true believers.

Kevin Pho: So what is your recommendation to pediatricians today who are treating or need to refer nonverbal autistic patients?

Ronald L. Lindsay: What they need to do is go and read up on the recommendations from the international board basically saying that DIR/Floortime and other non-aversive behavior modification methods are the way to go. The problem is that there are very few developmental pediatricians to be able to refer to. To be perfectly honest, in the North Carolina lawsuit, nobody has asked a developmental pediatrician to put their two cents worth in. That is kind of off-putting to me. Has developmental pediatrics sunk so low that it is no longer considered expert opinion?

Kevin Pho: We are talking to Ronald Lindsay. He is a developmental-behavioral pediatrician. Today’s KevinMD article is “A pediatrician’s reckoning with behavior therapy.” Ronald, let’s end with some take-home messages that you want to leave with the KevinMD audience.

Ronald L. Lindsay: Take-home message: Basically, use your common sense. If people are essentially torturing your children in order to get them to behave, that is not right. When the Life article that came out in 1965 came through, Bruno Bettelheim said: “The parents are not the monsters. The kids are the monsters.”

Children with autism are not monsters. They are people like you and I. They are neurodivergent. They have a different wiring system in their brain, and we need to celebrate those differences because sometimes it yields very good results like Teslas and Starship, because Elon Musk is on the spectrum. So is Bill Gates, and Microsoft has done wonders for the world.

Kevin Pho: Ronald, thank you so much for sharing your perspective and insight. Thanks again for coming on the show.

Ronald L. Lindsay: Thank you very much for having me and for publishing my articles.