Vínculo terapêutico: o estado da arte nas intervenções baseadas em ABA com crianças com autismo

Abstract

Different health fields have investigated the therapeutic alliance to assess its effects on treatment outcomes, generally by measuring it through verbal reports—which, however, cannot be used with people who have communication and language deficits, such as those with autism spectrum disorder (ASD). Moreover, a review of the literature reveals gaps in the definition of the therapeutic alliance and in the assurance of assent in therapeutic interventions involving protected populations. This work aimed to analyze studies on the therapeutic alliance in applied behavior analysis (ABA)–based interventions targeting children with ASD, to identify: (a) the definition of therapeutic alliance, (b) the responses considered dependent variables, (c) the procedures applied, (d) the metrics used, (e) the intervention effects, and (f) the assurance of assent and how it was described. A literature review was conducted in the following databases: PsycINFO, CAPES Portal, PubMed, Brazilian Digital Library of Theses and Dissertations, SciELO, and Google Scholar, using the terms "autism AND children AND therapeutic alliance", "autism AND children AND rapport", "autism AND presession pairing", "autism AND children AND pairing", "autismo AND terapia AND vínculo" and "autismo AND aliança terapêutica". Empirical studies were included if they were (a) in Portuguese or English; (b) used at least one of the expressions “vínculo,” “vínculo terapêutico,” “aliança terapêutica,” “aliança de trabalho,” “rapport,” “therapeutic alliance,” “working alliance,” or “presession pairing”; (c) involved participants up to 12 years old with ASD; (d) followed a behavior-analytic approach, as indicated by the presence of ABA terminology or expressions such as “behavioral analysis,” “behavioral intervention,” and “behavioral treatment”; and (e) treated the therapeutic alliance as either a dependent or an independent variable. After applying these criteria, eight studies were assessed. The results revealed that studies were limited by small sample sizes, lack of evaluation of participant assent, and absence of consensus in the terminology and definition of therapeutic alliance—sometimes framed as client–therapist social interactions, other times emphasizing topographical aspects of the dyad (smiling, eye contact, physical proximity), without a clear functional definition. Some studies examined whether alliance building can be promoted through specific interventions, such as presession pairing (PSP), and the evidence suggests that therapeutic alliance formation serves as an effective antecedent for fostering client–therapist social interactions and learning new responses, including increased frequency of children’s social responses, improved academic performance, and reduced frequency of problem behaviors. Despite advances in understanding how to measure and build the therapeutic alliance, a clear relationship between alliance strength and intervention outcomes has yet to be established