In UK clinical practice, the way intervention goals are chosen is central to evaluating whether a therapy supports dignity, autonomy and wellbeing. Guidance from the NHS, NICE and the National Autistic Society (NAS) emphasises that support for autistic people should build communication, participation, self-advocacy and emotional safety, rather than attempting to make a person “less autistic.” Within this rights-based framework, concerns about goal selection in Applied Behaviour Analysis (ABA) and relationship-based therapies (such as DIR/Floortime, RDI and parent-mediated approaches like PACT) are handled very differently.
1. How ABA-Based Therapies Typically Select Goals
The Cochrane-style review of Early Intensive Behavioural Intervention (EIBI) describes ABA programmes as highly structured, usually 20 – 40 hours per week, focusing on breaking skills into measurable steps taught through repeated trials. Targets typically include IQ, language, adaptive behaviour and school-readiness skills.
The NIHR HTA on ABA confirms that many programmes rely on predefined curricula and therapist-selected goals, although parents are sometimes consulted.
Reinforcement and Mastery Criteria
ABA uses contingent reinforcement to shape specific behaviours. Skills are considered “mastered” when accuracy meets predetermined criteria. This approach can be effective for teaching certain skills but raises questions about whether goals reflect the child’s priorities or comfort.
Focus on Normative Developmental Targets
The meta-analysis by Yu et al. found ABA-based interventions primarily targeted communication operants, socialisation, IQ and adaptive functioning using standardised tests. Critics argue that goals such as eye contact, reduced stimming or “indistinguishability from peers” may promote masking.
Autistic-led critiques, summarised in Abolitionist Neurodiversity writing, argue that ABA goal selection can reflect neurotypical norms rather than autistic preferences.
Social Validity and Autistic Perspectives
A social-validity study of PRT an ABA-derived NDBI found autistic adults approved of child-choice elements but criticised goals that pressured speech or eye contact without regard to sensory or emotional needs (Schuck et al.).
Limited Harms Reporting
A systematic review of early-intervention trials found that <10% mentioned adverse effects, and even fewer recorded them (Bottema-Beutel et al.). Trauma research mapping highlights community reports that behavioural interventions can be distressing when goals ignore a child’s signals (Kerns et al.).
These concerns often centre not on the basic principles of learning theory, but on who chooses goals, what counts as success, and whether distress is treated as behaviour to extinguish rather than communication to understand.
2. How Relationship-Based Therapies Select Goals
In the DIR/Floortime RCT (Pajareya & Nopmaneejumruslers), goals focused on shared attention, emotional reciprocity and symbolic play. Families were coached to follow the child’s lead. Progress was assessed using emotional-development scales, not compliance metrics.
A 2023 systematic review (Geraldine Dawson’s team) found consistent improvements in social-emotional development, though studies were small.
RDI and Social-Pragmatic Approaches
Relationship Development Intervention (RDI) targets “experience-sharing communication” and flexible thinking. But early RDI studies were uncontrolled and small (Gutstein; Bugnariu).
The developmental social-pragmatic review (Binns & Oram Cardy) describes DSP models as child-led, with goals centred on engagement, joint attention and emotional coordination.
Parent-Mediated Approaches: PACT
The PACT trials (Pickles et al.) aim to improve social communication by helping parents become more responsive, synchronous and attuned. Goals are tailored to each family through video feedback. This approach avoids prescribing specific child behaviours and prioritises mutual comfort and engagement.
Ethical Orientation
Relationship-based therapies emphasise:
- co-regulation
- emotional safety
- authentic communication
- child-led engagement
This aligns closely with NAS PBS principles: support should “never try and make someone less autistic” and must prioritise dignity, autonomy and the person’s emotional wellbeing.
3. How the Models Differ in Handling Goal-Selection Concerns
Autonomy and Participation
- ABA: Goals often predefined; child choice varies by model; risk of compliance-focused goals.
- Relationship-based therapies: Goals built around the child’s interests and emotional needs; parents collaborate closely in shaping outcomes.
Risk of Masking and Normalisation
- ABA: Some targets (eye contact, reduced stimming) may promote masking.
- Relationship-based: Prioritise communication and connection without requiring neurotypical behaviours.
Responsiveness to Distress
- ABA: Distress may be interpreted as maladaptive behaviour requiring intervention.
- Relationship-based: Distress viewed as communication and a signal to adjust interaction.
Alignment with UK Guidance
NHS and NICE guidance emphasise play-based social communication, functional understanding of behaviour and emotional wellbeing not compliance or normalisation (CG170; QS51). Relationship-based goals align more closely with this ethos.
Takeaway
ABA and relationship-based therapies differ fundamentally in how goals are chosen and whose priorities shape them. ABA tends to define targets as discrete, measurable skills determined by clinicians, whereas relationship-based models prioritise co-regulation, engagement and emotional connection led by the child’s interests. UK frameworks from the NHS NICE and NAS provide a clear benchmark for ethically acceptable goal setting: interventions should promote dignity, autonomy, participation and authentic communication rather than pursuing normalisation. Both approaches require more research on long-term wellbeing and trauma but only relationship-based therapies are consistently aligned with the UK’s rights-based, person-centred standards for goal selection.
If you or someone you support would benefit from early identification or structured autism guidance, visit Autism Detect, a UK-based platform offering professional assessment tools and evidence-informed support for autistic individuals and families.
