Why We Rejected ABA

When I consider my response to the question "what are your goals for Katie?" I am struck by the things I did not say as much as the things I did say. I didn't say I wanted her to be more compliant, to behave differently or to more closely resemble her peers. Neither did I respond with a list of behaviors divided into three categories (those I wanted to keep, those I wanted to alter, and those I wanted to eliminate), because to do so would imply that I thought it was up to me to decide what kind of person Katie would become. I said I wanted to be able to talk to her, meaning that I wanted to have a real relationship with this beautiful child.

We assume that many of our readers can empathize with our early search for answers. Like us, you probably did more reading in one month than most college students do in an entire year, and you did it while you were dog-tired and emotionally distraught. We know how you felt. All that flowery language we so often see about parental input in treatment decisions and special education planning isn't worth much if you're too upset to think straight.

For a while, we found that the more information we read, the more confused and depressed we became. When Katie's pediatrician directed us to the work of Stanley Greenspan, the fog suddenly lifted. His beliefs on the nature of autism and his method for treating it resonated with us because, for the first time, we heard someone who addressed our goals for Katie and certainly expressed them more clearly than we had, up to then.

"The primary goal of intervention is to enable children to form a sense of their own personhood."

Stanley I. Greenspan

Sounds Like Us:		Sounds Like Pavlov:
DIR The assumption that children with PDD tend to remain relatively unrelated to others, rigid, mechanical, and idiosyncratic (as stated in DSM-IV) is not supported by our recent clinical experience. With early diagnosis and a comprehensive, integrated, and developmental relationship-based treatment approach, many children originally diagnosed with PDD are learning to relate to others with warmth, empathy, and emotional flexibility. We have worked with a number of children diagnosed with autism or PDDNOS between the ages of 18 and 30 months, who, now older, are fully communicative (using complex sentences adaptively), creative, warm, loving, and joyful. They attend regular schools, are mastering early academic tasks, enjoy friendships, and are especially adept at imaginative play. Stanley Greenspan, The Child With Special Needs, pp 7-8.		ABA Applied Behavior Analysis employs methods based on scientific principles of behavior to build socially useful repertoires and reduce problematic ones...The behavior analytic view is that autism is a syndrome of behavioral deficits and excesses that have a neurological basis, but are nonetheless amenable to change in response to specific, carefully programmed, constructive interactions with the environment. Gina Green, Behavioral Intervention for Young Children with Autism. Texas: Pro-ed (1996), pp. 29-30.

We also found resonance in the words of Alfie Kohn, shown below. To accept a behavioral approach to intervention, we felt we would have to redefine Katie as little more than the sum of her observable behaviors. If we reduced our treatment of our daughter to a series of rewards and punishments, we not only devalued her behavior, but we also devalued her as a person.

Few readers will be shocked by the news that extrinsic motivators are a poor substitute for genuine interest in what one is doing. What is likely to be far more surprising and disturbing is the further point that rewards, like punishments, actually undermine the intrinsic motivation that promotes optimal performance....

The first explanation (of why rewards undermine motivation) has an appealing simplicity to it and seems to make sense on the basis of our real-life experience: anything presented as a prerequisite for something else -- that is, as a means toward some other end -- comes to be seen as less desirable. "Do this and you'll get that" automatically devalues the "this. "

Alfie Kohn, Punished By Rewards, NY: Houghton Mifflin (1993), p. 68., 76.

From Lovaas

Laws of learning apply to individuals with deviant organic structure as they do to individuals with less deviant structure. These programs start out with the most simple tasks, such as how to teach a child to sit in a chair, how to help him attend to his teacher, and how to better manage disruptive behaviors....

Developmentally disabled persons have to work particularly hard. Their work is to learn, your job is to teach. The responsibility is shared. With responsibility, the developmentally disabled individual takes on dignity and `acquires' certain basic rights as a person....They have no right to act bizarrely, many professional opinions notwithstanding. On the contrary, you have a right to expect decent behavior from your children. If you work hard for your child, he should be grateful, work hard, and show affection to you in return. You have to teach him that, and the programs in this book will help you do so.

O. Ivar Lovaas, The ME Book, Texas: Pro-Ed (1980).

We found Lovaas' words especially disturbing. Like so many behaviorists we have encountered over the years, his tone seems to us to give the impression that parents and therapists are in an adversarial relationship with the child - as if the child, who cannot display "decent behavior," is the enemy. Perhaps if we resented Katie's condition enough to describe her as an "individual with deviant organic structure" who had "no right to act bizarrely," or had some work to do before she deserved "certain basic rights as a person," we might have found, in Applied Behavior Analysis or Discrete Trial Training, all that we needed to transform her from what she was into what we wanted her to be. Unfortunately, we have never used such language to describe Katie and we doubt other parents have spoken similarly of their children.

"Give me a fish and I eat for a day. Teach me to fish and I eat for a lifetime."

Our main reason for rejecting a behavioral approach as our general intervention method was that, to us, it appeared to be something of a top-down, outside-in approach. Giving Katie a repertoire of socially acceptable behaviors to replace her unacceptable ones seemed very much like, well, giving her a fish. Our goals for Katie were different. We wanted to teach her to fish.

Incorporating ABA into DIR Programs

Our rejection of behavior modification as a general intervention method should not lead you to conclude that we believe it has no value whatsoever as a specific therapy. It just isn't enough. ABA can be very effective in altering behavior, but it should not claim to do anything more. A person is not simply the sum of his or her behaviors. We believe ABA is a tool which can complement the effects of Floor Time, especially in children who have not developed any imitation skills. It is the DIR framework, however, not the behavior modification techniques, that provide the context in which new skills can be used. We do not believe ABA should be used to stamp out behaviors that we just don't like because we are afraid these behaviors make our children look different.

Monica Osgood, director of Celebrate the Children, uses behavior modification techniques for specific children in her program, but does so within the DIR Model. She writes

"Behavior modification and self-monitoring techniques are implemented when needed to change specific inappropriate behaviors. If a child’s behavior is disruptive, socially inappropriate or dangerous staff takes data to determine the function of the behavior. Once the function is identified a behavior plan is written for the child. This plan consists of an intervention strategy, social skills training and sensory support if warranted. Social skills training and DIR are a part of every behavior plan to strengthen the developmental weaknesses responsible for the behavior and to teach replacement behaviors.

"Often children in the mainstream require some behavioral support to facilitate self monitoring and independence (especially children who have been exposed to more rigid interventions in the past or have severe sensory disturbances). This support usually consists of a plan to ensure consistency between staff and parents in responding to the child, sensory breaks if needed and visuals to remind the child of expected behavior, rewards or consequences, steps to activities and schedules."

Some Risks of Intensive Behavioral Programming

Intensifying rigid or mechanical behavior
from Stanley Greenspan, MD

One of the most common unhelpful approaches is to lose sight of the developmental progression the child needs, and instead' to zoom in on particular skills in a fragmented or isolated way. For example, a child may be aimless and distracted A parent or therapist may be trying to get the child to put a square block in a square hole. The child may do everything but look at the adult and try to copy what the adult is doing. Frustrated by the child's inattentiveness, the therapist or parent (often the parent copies the therapist) may hold the child's face and insist that the child look at him or her. Next one may try to get the child to listen by talking in a repetitive monotone (much like a computer voice in a tram car at an airport). If the therapist has been influenced by behavioral schools of thought, he may add on a reward every time the child does look at him The therapist might offer verbal praise (also delivered in a computerized monotone), "Good boy. Good boy. Good boy," as well as a piece of candy or other treat.

With such mechanical and rigid approaches it is not atypical for children with autistic spectrum/pervasive developmental disorder patterns to become more stereotyped and more perseverative as they grow. One needs to consider the hypothesis that the types of overly rigid and structured interventions that have been organized on behalf of these infants and children in part support rather than remediate their more mechanical behavior.

Stanley I. Greenspan, MD
Reconsidering the Diagnosis and Treatment of Very Young Children with Autistic Spectrum or Pervasive Developmental Disorder
Zero to Three
National Center for Clinical Infant Programs
Volume 13 No.2 October/November 1992

Prompt Dependence from Overuse of Discrete Trial Training
from Julie Donnelly, Ph.D

Unfortunately, focus on the one-to-one discrete trial format exclusively can train behavior that is not meaningful, generalized or spontaneous. The child may develop "splinter skills" but not make general applications. This training model does not take into account sensory problems that may underlie the unusual behaviors, or communication difficulties. Some individuals experience increased anxiety, perseveration and rigidity from this intense level of programming. Children need time for spontaneous play and to learn to be a child. They need social interaction with other children. They need to understand how to learn in groups and not become one-to-one prompt dependent. If we want these individuals to be able to function in our schools and in society, they will need to move past the one-to-one discrete trial format into a structured classroom with the opportunity for typical childhood experiences.

Julie A. Donnelly, Ph.D.
Senior Autism Resource Specialist, Project ACCESS,
The Pros and Cons of Discrete Trial Training.

The Question of "Recovery"
from Elizabeth Tsakiris, M.Ed, M.A.

Lovaas's claims for "recovery" of 47% of his experimental group were based on the children's placement in a regular education classroom and on the result of IQ measures (pre- and post-treatment) (Lovaas, Smith, & McEachin, 1989). The use of IQ as a measure of progress, let alone "recovery," from autism is seriously problematic.

Most important, as pointed out earlier, low IQ is not the distinguishing characteristic of autism and, while gains in IQ are welcome, they do not indicate improvement in many of the most critical autistic patterns. Individuals with autism can have high IQ scores and have severe deficits in abstract thinking (e.g. making inferences), emotional regulation, social behavior, the capacity for empathy and understanding feelings.

Elizabeth Tsakiris, M.Ed., M.A.
Evaluating Effective Interventions for Children with Autism and Related Disorders: Widening the View and Changing the Perspective
ICDL Clinical Practice Guidelines, Part Eight, Chapter 31, p.762

Restraints and Aversives

It is the opinion of The Asperger's Express that incorporating the use of restraints, either physical or mechanical, or aversive stimuli into the "behavior plans" of developmentally disabled individuals is abusive. While the use of brief physical restraint may be justified in emergency situations to prevent individuals from harming themselves or others, such situations should be extremely rare. We find no justification for the use of aversive stimuli (white noise helmets, blindfolds, ammonia inhalants, electric shocks, etc.) in any situation. We believe that the use of aversives can never be construed as "treatment" and we agree with the Autism National Committee's position below.

Left: Abbie Bowden was restrained 14 times in one day in her public school classroom.

The use of aversives is a human rights issue and a civil rights issue. When we allow punishments to be used on persons with disabilities which would be illegal if used on persons without disabilities, we are denying them equal protection under the law. Even our other devalued populations - people who are elderly, homeless, or in prison - cannot legally be "treated" with aversives, nor do we permit animals to be trained or treated by these means

The Autism National Committee
Myths and Facts About Aversives

To Learn More
The Asperger's Express has devoted a separate section of our web site to the issue of restraints and aversives, including their use in New Jersey, which can be accessed from the navigation bar.

Next, What Will Go Wrong