On Absurdly Poor Criticism And Advocate Misconduct, Part One

On September 14, 2013, exactly a month before I started writing this post, I was contacted by a colleague who expressed an interest in changes in behavioral practice since Lovaas's original methods and models of clinical treatment.

During the resulting exchange, I attempted to explain a variety of things related to behavior analysis, ranging from how ABA is not a treatment method to the relationship between ABA and PBS (the short version is that PBS is a brand-named philosophy regarding how to go about conducting and using ABA research). I also provided her with a number of assorted articles and writings on the subject, including a piece of my own work which acted as an overview.

I ended the exchange on something of a positive note, hoping that the information would help. The positive note, however, did not last.

This is what she wrote... or, at least, the currently-published version. There has been a rather spectacularly intellectually dishonest edit in the interim. It's, to put it mildly, an extraordinarily poor critique. The arguments are, by and large, spectacularly off-base, and her abuse of my writing is glaringly obvious (if not as much so as before the edits).

That said, I should probably discuss what this means and why it's a problem before I get into a detailed critique of the piece itself.

Contrary to what some people apparently believe, saying that a critique is poor does not mean that one disagrees with its conclusions or that the critique does not deal with real problems. It is saying that the critique misidentifies the issues involved and/or argues from a position of misunderstanding or prejudice.

In this case, the author is attempting to argue that all forms of applied behavior analysis are inherently unethical -- a very, very strong conclusion, one that simply does not follow from the evidence (such as it is) and arguments (such as they are) that she presents. Saying so isn't defending ABA, and certainly isn't excusing, justifying, or apologizing for the assorted abuses with which people have valid complaints.

This is important for several reasons -- not the least of which is that poor criticism serves to distract from real issues, detracts from good criticism, and confuses issues in ways that impair efforts to reform things.

To illustrate this, let's take a very different example, one that most of us can rapidly identify, easily understand, and generally make easy sense of: one of the more disgusting things which occurs whenever news story publishes a story about a black man raping a white woman.

Rape is obviously wrong: it's a gross violation of  a woman's bodily autonomy, a dehumanizing act which can easily (and often does) destroy her life. It is very difficult to think of a worse violation of someone's personhood... and the ethnicity and skin color of perpetrator and/or victim is utterly irrelevant to this.

Unfortunately, however, some people insist on making the moral issue here about race in a variety of ways. One of the simpler (and more vile) of these is to simply state that the act was wrong because a man like that (a black man, not a rapist) has no business sexually touching a White woman.

This is an absurdly poor (and racist) criticism of rape. It is one that needs -- urgently -- to be shouted down and combated whenever it pops up.

Referring to this sort of thing as poor discussion or off-base criticism is very much not excusing the heinous criminal act to which the alleged criticism was directed. It is simple truth.

The race thing serves to distract from the real problem. To the extent to which it gets attention, it's distracting people from paying that same attention to other, more relevant, criticisms.

But... let's say that some people actually took it seriously. Let's further say that they then tried to use it as the basis for political reform efforts.

These efforts would be useless at best and harmful at worst. In fact, that particular criticism can pretty much be considered a form of rape apology in and of itself: if the rape of a white woman by a black man is only heinous because of the race difference, what's wrong about a white man raping a white woman?

More, such "reform" efforts would likely target and harm completely innocent interracial couples. In fact, such prejudices and acts have historically caused very substantial harm in the form of blatantly racist legislation and various racial prejudices for just this reason.

Obviously, this has little directly to do with the ABA article which started this discussion, but does serve to illustrate a few very important points: 1) poor criticism is rarely helpful; 2) poor criticism is often harmful, even when its conclusions may be correct... and 3) stating that an argument is poor is not the same thing as stating that its conclusion is wrong.

In Part Two of this series, I will hopefully get to precisely why the specific critique that started this is poor and unlikely to be helpful. In Part Three, I will discuss just why I'm taking such pains to lay out these problems, why a simple blog post like that has lead to me starting an extended blog-rant, just what followed from the situation, and why it's taken me so long to post all of this.

On Exhaustion

Over the last month or so, I have been pushing myself pretty hard on the social/political/advocacy front, mostly trying to fight a battle that I'm utterly unsuited for. This has left me rather thoroughly exhausted, emotionally speaking, and my blogging has suffered for it.

I'm sorry about that.

On the other hand, I can't allow peddlers of pseudoscientific medicine endanger children -- and especially not the children who have entrusted to my care. That sort of thing takes priority over blogging, no matter how exhausted my efforts leave me.

I also attended a colloquium presented by a very prestegious behavior analyst yesterday. Specifically, he was presenting research which attempted to determine whether conditioning research (originally done on pigeons) would apply to the use of FCT to reduce problem behavior in children.

The people implimenting the program weren't even blinded to the specific experimental hypothesis. Gyah. When the entire experimental response is explainable entirely by expectency effects, you know you have poor internal validity...

On Shock

I'm mostly caught up on the newsfeeds and blogs that I follow. This is after effectively missing three days, and dedicating most of two days specifically to catching up.

Somehow, I think I try to follow too much.

Writing on the articles I've been planning to review will, however, have to wait... as I literally can't find my copies of them. I'd print out replacements, but my printer's broken, and I find it difficult to review an article while needing to switch between windows to read it and write about it.

While looking, however, I found my printed copy of what is easily the worst article I've ever read. In other words, it's the closest thing I have to a prototype of "bad science" in the peer-reviewed literature.

And no, papers in Medical Hypotheses and the like don't count. They're not peer-reviewed.

Anyway, that paper is a "wonderful" little piece (notice the sarcasm) by van Oorsow, Israel, von Heyn, & Duker (2008) entitled "Side effects of contingent shock treatment".

I originally came across this paper around a year ago. I summarily ignored it.

I came back to it, however, earlier this (calendar) year. As part of one of my classes, I was required to do a brief review of the literature on one topic and summarize the methodology of a few papers on it. I chose contingent electrical stimulation -- not because I liked the topic, but rather because I viewed it as an excuse to familiarize myself with the literature on it... and thereby improve my ability to counter that literature.

My paper's section on this steaming pile of crap reads:

Van Oorsouw et al. (2008) attempted to evaluate the side effects of the use of contingent shock to treat the "severe problem behaviors" (p. 513) of nine students at the Judge Rotenberg Center (JRC) in Canton, MA who showed "severe forms of SIB and aggressive behavior" (p. 514). The shock devices used were JRC's graduated electronic decelerator model one (GED-1).

A nonconcurrent quasi-multiple baseline across participants design was used. The length of baseline in each subject was the difference in time between their arrival to JRC and court approval for the use of contingent skin shock. During baseline conditions, DRO procedures, a token system, a response cost system, and contingent restraint were in effect. These procedures were also in effect during treatment conditions (van Oorsow et al., 2008).

During treatment conditions, skin shock was delivered contingent on SIB and/or aggressive behaviors. Subsequently, a staff person or teacher who administered the shock would explain the contingency and prompt the student to continue what they were doing prior to the shock (if needed). Following this, the electrodes would be rotated slightly and the time of administration would be recorded (van Oorsow et al.,
2008).

Four categories of target behaviors were also recorded: positive verbal and nonverbal utterances (PVNU), negative verbal and nonverbal utterances (NVNU), socially appropriate behaviors (SAB), and off task behaviors (OT). Van Oorsow et al. (2008) defined these behavior categories only by example.

Data was recorded by 10s partial interval recording based on 10-min videotapes of randomly chosen points of time in the participants' day. All recordings were selected so that teachers and staff were not applying reinforcing contingencies within them. Average IOA was 95.48%. Data was analyzed by visual analysis by seven clinicians. Mean agreement for change across clinicians was 78% for PVNU graphs, 92% for NVNU graphs, 91% for SAB graphs, and 89% for OT graphs. Agreement ranged from 57% to 100%. All participants were evaluated as having either improved or not changed in each category. Group analyses were not conducted (van Oorsow et al.,
2008).

Data on one participant ("S.S.") was not taken in regard to SAB because she had "severe mental retardation, and who, by definition, failed to show any form of SAB" (van Oorsow et al., 2008, p. 522). Despite this assertion, S.S. is listed as a girl with moderate mental retardation and autism within the study's demographic table. Van Oorsow et al. do not provide support for this assertion.

Additionally, this design is not appropriate for a full analysis of side effects, as it only allowed for the possibility of four specific negative effects (i.e. lowered PVNU, increased NVNU, reduced SAB, and increased OT) and only included nine participants. As it is common practice to report effects that occur in less than one percent of the treatment population as side effects of a treatment and to take them into account when planning a course of treatment, the number of participants was too small to allow a comprehensive evaluation of side effects. Additionally, it is common practice to take into account a wide variety of effects, including those that are only directly available as private events (c.f. Eli Lilly and Company, 2006). As such, the study fails to provide sufficient support for van Oorsouw et al.'s (2008) assertion that "the objection that CS should not be used due to associated negative side effects, fails to be inconsistent with the results of this study" (p. 523).

This, of course, is only a tiny fraction of the problems with the paper. For one thing, I have reason to suspect that they misrepresented their procedure in the article. A careful reading of the article and comparison to publically available documentation will indicate that standard procedure at JRC involves a change of setting and activity schedule upon receipt of court approval for the use of shock, something that the article did not report. Assuming that this was the case... well, let's just say that the ethics of their procedure were even shittier than my summary suggests.

And, of course, since it was a purely methodological paper, I didn't even begin to directly touch on the ethical problems with what they did. Suffice it to say that they were many and manifold.

For instance, one of the subjects was an eleven year old boy whose only diagnoses was oppositional defiant disorder and "mild" mental retardation. Another was a nineteen-year-old woman who had a diagnosis of post-traumatic stress disorder.

Words fail me here. The horses and deer are prancing.

Oh, and there are the usual randomization issues, selectivity bias... yeah, all of those. Poor, poor study on so many levels it's not funny.

References:

Eli Lilly and Company (2006). Prescribing Information (Prozac Label, 2006). Retrieved February 28, 2009, from http://www.fda.gov/cder/foi/label/2006/018936s076lbl.pdf

van Oorsouw, W., Israel, M., von Heyn, R., & Duker, P. (2008). Side effects of contingent shock treatment. Research in Developmental Disabilities, 29, 513-523.

Management of Children With Autism Spectrum Disorders

Every so often, I find a research article that makes me want to celebrate. On the other hand, I also periodically find articles that make me want to slam my head against a wall in response to their sheer stupidity.


And, although it's rarer, I do occasionally find an article that makes me want to do both. For obvious reasons, it's almost inevitably different sections of the same article that do each. I haven't had the experience of having both reactions to the same sentence... or the same paragraph, for that matter.

I bring this up because that last is the sort of reaction that I had to this article (also findable here), which was published two years ago in the absurdly prestegious journal Pediatrics.

Entitled "Management of Children With Autism Spectrum Disorders", the article is basically a comprehensive introduction to autism, intended for general practitioners so that they can familiarize themselves with the field for whenever they get an autistic patient.

It's a nice idea -- and the journal it got published in is probably the one which pediatricians are most likely to read. Unfortunately, a good bit of the information contained within is biased or just plain wrong.

Now, to be fair, the article is two years old and a lot of the studies refuting points in it were published in the last two years (thanks, Michelle!). Some of it, however, was just plain wrong, even with what we knew then... and to say that the clinical philosophy statement is questionable is a major understatement.

To quote:

The primary goals of treatment are to minimize the core features and associated deficits, maximize functional independence and quality of life, and alleviate family distress. (pp. 1162-1163)

The first clause of this, "to minimize the core features and associated deficts" comes in direct conflict with the remainder for the simple reason that autism isn't just a set of deficits. "Minimizing the core features" of autism includes those srengths as well as weaknesses -- it's trying to turn an autistic person (to the degree possible) into a non-autistic person. This is pretty thoroughly appalling... but almost to be expected.


The article also drags up the whole theory of mind myth, the joint attention thing, the myth of the "need" for intensive behavioral intervention... the list goes on and on. In general, it drags up a crapload of invented, so-called "knowledge" and passes it off as truth.

Hell, it even manages to miss the fact that autistic children learn and develop in ways completely out of line with neurotypical developmental timetables and skill hierarchies.


The worst section of the paper, however, is the section on applied behavior analysis. The errors start with what ABA is... and just keep piling up from there. If you believe the article, ABA is:

... the process of applying interventions that are based on the principles of learning derived from experimental psychology research to systematically change behavior and to demonstrate that the interventions used are responsible for the observable improvement in behavior (p. 1164).

... umm, no.

Cooper, Heron, & Heward's (2007) textbook, Applied Behavior Analysis (2nd Edition) is pretty much considered (for the time being, anyway) the definitive reference on ABA. Its definition is:

Applied behavior analysis is the science in which tactics derived from the priniciples of behavior are applied systematically to improve socially significant behavior and experimentation is used to identify the variables responsible for behavior change (p. 20).

In other words, Myers et al. are wrong on two major points:

• ABA is a science. The process of using tactics derived from that science is technically referred to as clinical practice based on ABA. While this may seem like quibbling, it's actually a fairly important distinction. Like any science, ABA offers predictions -- "what will happen if I do this?" -- theories, and very little else... although there are certainly interventions derived from it and experimental tests of those interventions (with the tests falling under the "ABA" category, but the manuals arguably not).
• Practice based on ABA does not use "the principles of learning derived from experimental psychology research". ABA-based methods use the principles of behavior derived from EAB and ABA research. While some of these can be described as (or can act as) principles of learning, EAB and ABA research is only a subset of experimental psychology research... and much of the non-behavioral research has been devoted to learning. Simply put, Myers et al.'s definition suffers from both deficiency and contamination.

I could go on to critique the other various errors in this section... but won't. Frankly, the fact that the article couldn't even get the definition of ABA right about sums up the accuracy of the article's ABA section... and makes me wonder how the heck it got published in Pediatrics of all places!

While I'm not overly familiar with the developmental treatment models, there are a number of issues with the article's section of them as well... although, to be fair, some of these may be flaws in the actual models themselves. The DIR model, for instance, "targets the core impairment in social reciprocity" (p. 1165) despite the fact that while such a deficit does exist, it certainly doesn't lie with autistic children!

The section on speech and language therapy is comparatively good (which shouldn't be confused with an unqualified "good"), but the recommendations the article makes regarding social skills instruction are, frankly, abominable from an etical standpoint (not to mention that it drags up certain fallacies regarding joint attention yet again).

I'm not even going to get into the section on comparative efficacy. Let's just say that it's at least better than the section on ABA... which means that it at least got the definition of its subject matter right.

The section on sleep disturbance, however, was just plain scary. Benzodiazepines? Zolpidem? Trazodone?!? By contrast, the reccommendation of zaleplon was almost understandable.

Its section on psychopharmacology wasn't much better.

There was also one line which made me blink and react in a manner fully consistent with typical usage of the acronym WTF. Specifically: "However, if a child with an ASD presents with symptoms such as chronic or recurrent abdominal pain, vomiting, diarrhea, or constipation, it is reasonable to evaluate the gastrointestinal tract."

This needed to be said?

After all of that, however, the article had some truly outstanding points. Its coverage of complementary and alternative medicine (AKA "woo") is excellent (barring, perhaps, its coverage of facilitated communication, which I can't comment too much on). One line that comes to mind as particularly noteworthy is:

Some treatments, such as intravenous chelation, may be particularly dangerous and should be discouraged. One child with autism died as a result of chelation with edate disodium... despite the facts that a causal association between mercury and ASDs has not been demonstrated, there is no scientific evidence that chelation is an effective treatment for ASDs, and the effectiveness of chelation therapy to improve nervous system symptoms of chronic mercury toxicity has not been established. (p. 1174, chemical formula of edate disodium omitted)

Another worthy line:

Educational programs should be individualized to address the specific impairments and needed supports while capitalizing on the child's assets rather than being based on a particular diagnostic label. (p. 1167)

In short, I have highly mixed feelings about this article... but at least reading through the contents of the reference section will keep me busy for a while.

My First FBA

I completed my first FBA yesterday. For reasons of confidentiality, I won't get too much into just what it was about, but it ran into a number of ethical issues (not the least of which is that the child in question is transitioning into Kindergarten in around a week).

That said, I'm particularly proud of one line from my suggested behavior plan, which I managed to get my supervisors to approve. The line in question is under the heading of "suggested preventative strategies" and reads:

• Allow [the child] to engage in harmless types of self-regulatory behavior.

The plan goes on to define "self-regulatory behavior" as explicitly including (but not being limited to) rocking and hand-flapping.

Of course, this is also followed by a line stating that any behavior which poses a physical danger to the child or his peers or cannot be accomidated within classroom activities is not harmless. It does, however, state that reasonable steps to accomidate this sort of thing within said activities (such as leaving room between him and other students so that he doesn't accidentally hit them while hand-flapping or providing a rocking chair for some seated activities) should be taken.

Aaah, if only all behavior plans had that sort of line...

Edit: Corrected a minor typo (the "m" in "limited" was missing).

A Lecture

Today, the practicum students at my site had a training. Officially titled, "The Behavior Communication Connection" and subtitled "The Nature of the Connection", it was essentially a lecture on the differences between modern ABA-based techniques (notably including PBS techniques) and the crap that some idiots practice and have historically practiced.

This isn't to say that modern ABA-based techniques are perfect. It's to say that they're better than the ethics-challenged stupidity that some people equate with them. Now if only we could get people to stop practicing said ethics-challenged stupidity...

In any case, other than one slide, it was a fairly decent presentation... although I will admit that I made my fair share of points and am evaluating it with those incorporated.

That one slide was entitled, "Why do Students with Autism have Difficulty Communicating?" Leaving aside the person-first formulation (and why is it that the people promoting this sort of language never ask the people with disabilities themselves? It's not like we've been keeping our opinions secret...), the answer was quite revealing.

Specifically, it stated: "Children with autism do not have the skills of typically developing children that assist in the acquisition of communication skills."

The most revealing part of this is the fact that it proceeded to give ten examples. Of them, six were false and four were drastic oversimplifications.

Autistic kids lack the ability to maintain attention? ... yeah. Right. This is even funnier given that the next item states that autistic kids lack the ability to shift attention. The contradiction should be pretty obvious.

Autistic kids lack the ability to take the perspective of others? Disregarding the fact that this is a skill which neurotypical kids "lack" relative to adults, my experience has been that autistic kids are quite good at taking the perspective... of other autistic kids. The fact that they can't take the perspective of non-autistic kids is something that's a given, but neurotypical kids can't take the perspective of autistic kids, either. Issues of this sort happen cross-culturally, too. I mean... people from other cultures blow the tiniest things out of proportion. What the heck is the big deal with accidentally showing someone else the bottom of your shoe?

Yes, that's sarcasm.

The next item, that autistic kids have overselective attention, is so rediculously oversimplified that it's not even funny. I've commented on this before, but autistic sensory systems process data in ways that are completely different from the ways that non-autistic sensory systems do so. Of bloody course they're going to find different things salient!

This is followed by a statement that autistic children lack in the ability to use new experiences to relate to previous experiences. Umm... no.

The slide continues along these veins for a while. I would, however, like to answer the question from my own experience.

Why do autistic students have difficulty communicating?

Because the people they're trying to communicate with ignore them when they try.

On Frustration

Throughout my clinical career, there have been a number of things which I've very much wanted to say, but haven't for a variety of reasons. These range from me being generally too polite to actually say them to me believing that doing so would be counterproductive.

For a variety of reasons, this post has been backdated. I won't say when -- or where -- I wanted to say these things, although I will elaborate (somewhat) on the contexts if asked. I also will freely edit this post to add additional unsaid comments as they occur -- and will not remark on my so doing. I won't necessarily add them to the end of the lists, either.

For the most part, all of this is to prevent these comments being tied to any given workplace or person. Given the nature of some of these, they could damage the reputations or careers of the people involved, and that is not my intention. It is, however, my intention to highlight some of the things that go on in the clinical field... and why I greatly prefer academia.

To professionals:

• If I'm implementing an extinction program, please don't undermine my efforts and reinforce an extinction burst.
• This goes double if the program is for aggression. Do you think it's easy to not react when a child is hitting you? Those punches can hurt.
• Damnit, when a child hits a teacher, the correct response is emphatically not to give the child cake!
• For the love of God, lady, how the Hell did you manage to pass the BCaBA exam without knowing what extinction is?
• Lady, I read the clinical research for fun. If I'm doing something you don't understand, just ask me. I'd be more than happy to explain. If you just interrupt, undermine my efforts, and then blame me when things get worse, it really isn't going to help my opinion of you or of your professional conduct.
• If you have a behavior plan to work on, please don't work on it in the classroom while the kids are just sitting there, bored. It's not only unprofessional, it's actively against the best interests of the children. This goes double if the plan isn't even for one of the kids in the classroom.
• If you work two full-time jobs which involve acting as caretaker of a mix of autistic children and adults, I am bloody well going to assume that you know what autistic literalism is. I am also going to assume that you know what autism is. Proving these assumptions wrong is not a good way to impress me with your professionalism.
• I attempt to hold myself to very high standards of both professionalism and compotence. However, I also expect certain minimum standards of these from my colleagues. If you are working as a behavior therapist, this means that I expect you to know what certain basic concepts -- like "extinction" and "reinforcement" -- are, and I do not expect you to attempt to ridicule me for using these terms.
• I had more than enough bigotry and ridicule during my secondary education, thank you very much.
• Anti-autistic bigotry and ridicule of autistic difficulties have no place whatsoever in a special education environment. Yes, I very much will complain to our boss about these things if you engage in them.
• Lady, I'm autistic -- with all that implies. I flat-out told you that well before I ever started to work with you. If you don't understand what that means, you have no business working in a school for autistic children. You have less business trying to teach them.
• If you need something, bloody tell me. I'm not necessarily going to pick up on it intuitively.
• If a child has been warehoused -- and probably abused -- for half of her life, chances are that institutional damage is a factor. More than a little sympathy and kindness is called for.
• Please stop talking in front of the children as if they weren't there.
• Your bigoted rant is making me physically ill. The fact that it is being made in front of the children is not a redeeming factor.
• ... you have two autistic sisters, work in the field, and can't deal with autistic literalism?
• "Personal style" is valid, to a point, but developing a true personal style does not consist of taking pieces and aspects of flawed therapies and methods and merging them into a personally-appealing whole. It consists of finding a way to operate within guidelines and boundaries of best practices that you are capable of and comfortable with.
  

To parents:

• If your son has stomach problems which have required him to be hospitalized in the past, and the hospital found a series of massive cysts in his stomach... please take him to a real doctor and not some natropath. I very much do not enjoy the way he screams in pain while clutching his stomach during lunch. I also very much do not enjoy trying to teach children who are in considerable pain, and I know exactly how much even a minor stomach lesion can hurt.
• (In regards to the previous) No, I do not think that some "all-natural" digestive enzymes will solve the problem.
• Lady, your nineteen-year-old starting to show an interest in pictures of scantily-clothed women is not a sign of precocious puberty or overly high testosterone levels... and certainly not a medical indication that he should be chemically castrated by the Geiers!
• (Smiling) No, I don't think that your child's motor difficulties are "the autism". I think they're a direct result of the megadoses of Vitamin B6 you've been giving him for the last few years.
• When your child starts to exhibit symptoms of acute hypervitaminosis A, you immediately stop all supplementation. You do not just reduce the dose by ten percent or so.
• Please stop feeding your child candy whenever he punches me... or you... or anyone else, for that matter. Do I really need to explain what you're teaching him by doing this?
• No, giving him a toy is not an acceptable substitute!
• Please start showing some common sense. (Over and over again...)
• No, hookworms are not a good thing for a child to have!
• Children coming to school stoned out of their mind tend not to learn much. This is not an autism thing.
• ... let me get this straight. You're doing the body ecology diet and yogurt enemas and yet you think you're not into the woo?

And I could think of plenty more...

Body Language, Facial Expressions, and Autism

A clinician recently wrote me, asking about why people on the spectrum have trouble reading facial expressions. This is, of course, a gross oversimplification.

While it's true that autistics have difficulty reading the facial expressions and body language of neurotypicals, autistics often have considerably less difficulty reading the facial expressions and body language of other autistics. In fact, autistic individuals usually find reading autistic facial expressions and body language easier than neurotypicals do. There's a pretty good first-hand account of the sort of thing that I'm referring to here. The comments on that are pretty eye-opening, as well.

On a similar note, a discussion of ABA on the ASAN's discussion list included the following anecdote (reprinted with the sender's permission):

A neurotypical teacher (who gets along with me just fine) was watching me doing some academic testing a couple of days ago with a student who is classic autistic, and she had to repress her laughter while she watched... because suddenly I was speaking a totally different social language (as in, being the real me), and she later said it was "wierd" to watch me "lose all my feelings," and yet he and I were clearly playing around and having a great time (the kiddo was laughing quite a bit, especially when I called him on some of the get-out-of-work-free behaviors he had learned because people don't normally understand him and like any kid would, he was playing it to the hilt). It baffled her. Especially when he then started giggling uncontrollably after he discovered that I was very good at eye-contact tag (letting him lead and just giving the briefest of glimpses at each other's eyes while I played "hard to find" by making him work to "catch" my eyes... he was intrigued by an adult that didn't force eye contact and then would actually dodge it to create a game).

That led to a rather long conversation about this very thing... that there are multiple social langauges, including the toned-down version.

There are similar issues with people from different cultures (For examples, I suggest studying the initial encounters between Americans and Japanese following Perry; I believe there were similar accounts involving the Chinese, but I haven't studied them in enough detail) as well, so I ultimately believe that it's not an issue of autistics having difficulty reading body language (and/or facial expressions) as I believe it's a matter of people in general having difficulty reading body language that's different from their own.

Quiet Time Humor

At my practicum site, there's a period called "Quiet Time" or, alternatively, "Nap Time". It's a period after lunch when we pull out the cots, turn out the lights, and (usually) turn on some soothing music.

This is done because of the belief that preschool children need an afternoon nap. While many of the kids agree, many others... don't.

As of late, I've been implementing a non-contingent reinforcement strategy for decreasing one child's disruptive behavior during this time period. Translated into colloquial speach, instead of behavior analytical jargon, this means that I've been giving him some toys to keep him from getting bored and raising a fuss.

Apparently, he has nicknames for at least some of the puzzles in the classroom, too. One of them is particularly worthy of note. The puzzle itself is fairly simple -- a wooden piece depicting a dentist at work in his office.

The kid's nickname? "Scary man puzzle".

I laughed.

What. The. HECK?

Recently (within the last week or two), I got into something of a debate with Michelle Dawson regarding the internal validity of single-subject designs. As a result, I've been spending some time reviewing the literature and looking for a design to pick apart. While doing so, I came across a paper entitled "Functional analysis of stereotypical ear covering in a child with autism."

The abstract -- the entire abstract -- is as follows:

We studied stereotypical ear covering in a child with autism. Results of a descriptive analysis were inconclusive but revealed a correlation between ear covering and another child's screaming. An analogue functional analysis showed that ear covering was emitted only when the screaming was present.

Way to avoid citing other literature, people.

The rest isn't much better. To quote the last paragraph of the paper:

These findings suggest that ear covering was maintained by negative sensory reinforcement (noise attenuation) and illustrate the importance of linking descriptive and analogue functional analyses when idiosyncratic events are implicated in behavioral maintenance. Whether a similar relation between ear covering and noise occurs for other children with autism awaits further investigation. However, the current data set implicates a previously unidentified source of reinforcement as one possible cause of stereotypical behavior.

Umm... that is most certainly not a "previously unidentified source of reinforcement". Documentation on what we politely call "sensory issues" in autism goes back a biiiiit further than 2003.

On Aversives, Punishment, and Language

One factor that complicates many of the debates surrounding applied behavior analysis is the fact that its technical language groups things together based mainly on their effects on specific (and usually observable) behaviors. While this makes it excellent for its intended purpose (analyzing behavior), it also makes said language extremely poor for use in an ethical debate.

To illustrate, let's take the hypothetical example of a boy -- let's call him "Chuck" -- who likes to act out in class. Let's also take three hypothetical teachers, "Jane", "Matt", and "Alletta", each of whom decided to take a different approach to making him behave.

Jane decided to assign Chuck additional homework on days when he misbehaved, gently informing him of her reasons whenever she did so. After a bit, Chuck realized that acting out in her class only led to more work and started paying attention more.

The second teacher, Matt, decided on a simpler course of action. He hooked a cattle prod to a remote control and strapped it to Chuck's back during class. Whenever Chuck acted out (or attempted to remove the cattle prod), Matt activated the device. After a few jolts, Chuck realized that both actions only resulted in terrible pain and stopped acting out, paying attention in a manner that only the truly terrified can.

The third teacher, Alletta, was an advocate of corporal punishment, but had promised Chuck's father that she wouldn't hurt him. As such, she instead called Chuck's best friend, Bill, to the front of the class and spent a few minutes torturing him whenever Chuck misbehaved, making sure that Chuck knew why she was doing so. Not wanting to see his friend hurt, Chuck quickly fell in line.

In the language of behavior analysis, all three of these teachers implemented the same basic strategy: punishment by contingent presentation of an aversive stimulus. All three strategies were punishment because they directly targetted and decreased an undesired behavior class (acting out), they were contingent because the strategy was only implemented when the behavior occurred, they were presentation of a stimulus because all three strategies involved giving Chuck something (be it extra homework, a painful shock, or a traumatizing emotional experience) and those stimuli were aversive because Chuck moved to avoid them (1).

This is not, however, to say that all three of those strategies were equally ethical. Very few people (outside school-age children, anyway) would have problems with what Jane did. Matt's actions were a somewhat exaggerated version of a highly controversial technique used in certain behavioral institutions (2). Alletta's actions, however, haven't been considered even remotely acceptable since the 1700s and even then, they were confined to punishing certain royals.

For those historians reading this, yes, I did name Chuck and the people in the third example after certain individuals. And while Matt's method may have prevented Ollie's eventual hissy fit, just imagine Jimmy's reaction!

To get to the point, however, I also don't mean that these strategies would all have the same effects. While all of them decreased the target behavior, Jane's strategy would have had the fewest unpleasant side effects.

The strategy closest to what commonly comes to mind when the term "aversive" is mentioned to people familiar with today's ABA establishment, however, is Matt's.

If this were an isolated case of misused or misunderstood terminology, it would be a fairly minor problem. Unfortunately, that isn't the case. The language of behavior analysis is -- perhaps unsurprisingly -- designed for analyzing behavior. As such, methods are categorized based on their effects on (usually specific and observable) behaviors and not their effects on the person who is behaving.

Ethical considerations, on the other hand, are almost always based on benefit and harm to people, something which the language of behavior analysis is decidedly poor at describing.

If this was widely understood, it wouldn't be a problem. Unfortunately, many people who use the techniques produced by ABA don't understand the distinction. The debates surrounding their use are often muddied by this.

As a general rule, people with postgraduate educations in behavior analysis understand its technical language and use it to talk about ABA's techniques. Everyone else... doesn't, although there are exceptions. Things get more complicated when terms used in ABA have or acquire different meanings outside of that language.

The debates surrounding aversives are, quite literally, a textbook example of this.



(1) According to Cooper, et al. (2007), the most influential textbook on behavior analysis used today, an aversive stimulus is defined as "a stimulus change or condition that functions (a) to evoke a behavior that has terminated it in the past; (b) as a punisher when presented following behavior, and/or (c) as a reinforcer when withdrawn following behavior." In this case, it's (b) that applies.

(2) While modern accounts usually don't involve literal cattle prods, instead involving a variety of other shock devices, there are accounts of literal cattle prods -- and improvised devices made from them -- being used as late as the early to mid-'90s.


References:

Cooper, J., Heron, T., & Heward, W. (2007). Applied Behavior Analysis (2nd Ed.) Upper Saddle River, NJ: Pearson Education, Inc.

The Pace of ABA Research

My class on behavior models in ABA (effectively a survey on the various things ABA has been used for) has just started its unit on ABA-based autism interventions. As part of this, we were instructed to read our textbook's chapter on stimulus preference assessment.

One paragraph stood out the most to me. Namely,

One antecedent condition that obviously affects the momentary effectiveness of a reinforcer is the continuum of deprivation and satiation of a stimulus. In animal research, the use of ongoing schedules of food and water consumption are commonly used techniques for maintaining the effectiveness of stimuli used as reinforcers. Naturally occurring events are rarely, if ever, disrupted in applied research. However, it has recently been demonstrated that reinforcers are more and less effective at different moments during a routine day. Vollmer and Iwata (1991) demonstrated the differential effectiveness of food, music, and attention during periods of satiation and deprivation....

In other words, food acts more powerfully to motivate people when they're hungry. What really bugged me, however, was the date of that citation. It's referring to a study published in 1991.

My initial reaction was something along the lines of, "It took you fifty years to figure that out!?!"

Then, of course, I realized that the paper in question might not be a seminal work.

Then I started pondering how the hell the word "seminal" acquired the meaning it holds in science today.

After eventually dismissing that as a pointless etymological tangent, I decided to look the paper (which is publically available) up.

In a moment of horror, I realized that it was.

Alphabet Soup!

Back when I was a kid, I used to like Campbell's Alphabet soup. Part of this was the preschool fascination with letters. Part of it was the taste.

Kids, in general, like alphabet soup. It's a great thing educationally, as well as being... well, better than some things... nutritionally.

To many adults, on the other hand, a different kind of alphabet soup is the bane of their existence. In a real way, this sort of alphabet soup has invaded our lives, thrusting such arcane acronyms as FBI, CIA, NSA, IRS, USSS, DEA, and NCIS... just to name a few of the more commonly mentioned examples within the US government.

Medicine, too, has its own alphabet soup. Ranging from HIPAA to MRI, it bombards us with labels like IRB that seemingly have no relevance to our day-to-day life. Every diagnosis seems to have its own inpenetrable jargon... to most people, anyway.

It should be no surprise that autism, too, has its own fair share of related alphabet soup, words like ABA, IBI, DTT, IEP, PT, and AS, just to name a few examples. Many of these acronyms are often misused.

To someone new to the world of autism, this can be... confusing, to say the least. As such, I've put together a little guide to them.

Do not expect this guide to be complete. If someone mentions an acronym to me that's not on this list, I'll go back and add it in (with a little thank you), but this initial version is just a guide to the ones I could think of offhand.

I've grouped these acronyms into two categories: those which are ABA-based and those which are not. There's some room for debate here, my classification of PBS as not-ABA being a prime example, but that would have been the case regardless of which direction I chose to in that case.

Not ABA

ADOS - The Autism Diagnostic Observation Schedule, a tool used to access the "symptoms" of autism.

AS - Asperger Syndrome, often (debatably) referred to as a "mild form of autism".

ASD - Autism Spectrum Disorder(s), any of the conditions classed as PDDs under the DSM.

NT - Neurotypical. Depending on use, either someone of "normal" neurology or having to do with non-autistic attitudes and/or society.

MMR - Vaccines used to immunize against measels, mumps, and rubella. Often blamed for kids "becoming" autistic despite a lack of evidence to support the view.

IDEA - the Individuals with Disabilities Education Act, a United States law which has considerable impact on the education of autistic individuals.

OT - Occupational Therapy. Also occasionally used to refer to an Occupational Therapist.

SLP - Speech-Language Pathology. Also, occasionally, Speech Language Pathologist.

PBS - Positive Behavioral Support, a breakoff movement from ABA. PBS methods typically differ from ABA methods mostly in marketing and attitudes.

PDD - Pervasive Developmental Disability, one description of what autism is. Other conditions classed as PDDs under the DSM-IV are Childhood Disintegrative Disorder, Rett Syndrome, Asperger Syndrome, and PDD-NOS.

PDD-NOS - Pervasive Developmental Disability - Not Otherwise Specified, the DSM-IV's catch-all diagnosis for anyone on the spectrum who can't be given a diagnosis of CDD, Rett Syndrome, AS, or autism.

CAN - Cure Autism Now, a predecessor group to Autism Speaks.

DAN - Defeat Autism Now!, a network of physicians, researchers, and so on who advocate nonstandard treatment methods for autism. Many accuse them of being quacks.

FEAT - Families for Effective Autism Treatment, a movement consisting primarily of the families of autistic individuals which is dedicated to the advocacy of intensive ABA-based treatment programs.

ASA - the Autism Society of America.

DSM - The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders.

DSM-IV - The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth (IV) Edition.

CDD - Childhood Disintegrative Disorder.

ASAN - the Austic Self Advocacy Network, an autistic-run group dedicated to championing the rights of autistic individuals.

ABA

ABA - Applied Behavior Analysis, the science of applying behavior analytic principles and theory to real-world situations.

BACB - the Behavior Analysis Certification Board, the group responsible for certifying behavior analysts.

BCBA - Board Certified Behavior Analyst, someone certified to design and oversee a course of ABA-based therapy (among several other things).

BCABA - Board Certified Associate Behavior Analyst, someone certified to implement behavior plans and conduct the day-to-day work of ABA-based therapy.

BIP - Behavior Intervention Plan, a plan (or document detailing a plan) to alter behavior.

NET - Natural Environment Teaching, a blanket term for teaching methods conducted in a natural or nautralistic setting.

IBI - Intensive Behavioral Intervention

EIBI - Early Intensive Behavioral Intervention, IBI starting at a young age.

DTT - Discrete Trial Teaching, a teaching method used as the basis of most early ABA-based autism interventions. In many minds and documents, DTT is equated with ABA.

PRT - Pivotal Response Training, a teaching method designed to target so-called "pivotal responses" such as motivation,

PECS - the Picture Exchange Communication System, a teaching strategy for communication skills.

VBA - Verbal Behavior Analysis, either the application of ABA to human interaction or a specific approach to language intervention.

AVB - Analysis of Verbal Behavior, another name for VBA.

JABA - the Journal of Applied Behavior Analysis, the flagship academic journal of ABA.

JEIBI - The Journal of Early Intensive Behavioral Intervention, a major ABA-based jounal and the flagship journal of the IBI movement.

This, of course, is an incomplete list. If you think of any others, feel free to comment with them and I'll consider adding them... with, of course, appropriate credit.

The ABA Establishment

As a grad student, I often read research articles -- more often than not because my teachers assign them. They like to assign articles, great big stacks of them that seem to take forever to work through... and, then, when I'm finally finished, it's just in time to start on the next stack.

Every now and then, however, one of them is particularly interesting or noteworthy. A 1999 paper by Koegel, Koegel, Harrower, and Carter published in the Journal of the Association for Persons with Severe Handicaps (24(3), 174-185) is one such.

The paper is entitled "Pivotal Response Intervention I: Overview of Approach" and is interesting for a number of reasons. On one level, the basic concept behind pivotal response intervention itself is fairly interesting and quite ingenious in a way.

More importantly, however, the paper seems to make a number of the things that are wrong with the behavior analytic establishment readily apparent.

After things which are common to the autism establishment as a whole (e.g. the strict-disability model), a disturbing pattern emerges.

For instance, take the following quote:

As mentioned, over the years, a substantial amount of research has identified a specific attentional characteristic displayed by many children with autism. This characteristic has been called "stimulus overselectivity" (Lovaas, Schreibman, Koegel, & Rehm, 1971). It refers to the tendency of certain children with autism to respond on the basis of a limited number of (frequently irrelevant) components in their environment (see Schreibman, 1997, for review).... Many children with autism, however, tend to respond to fewer and more irrelevant components (e.g. a bend in a picture card, as opposed to the relevant feature of the picture). Thus, children with autism may identify a stimulus by an irrelevant cue (Schreibman, 1997).

Given the sensory issues autistic people have -- often in manifold and varied form -- it's quite likely that the issue here is one of salience, and lies on a sensory level. Despite this, none of the relevant literature is cited... and the possibility is not referenced. Were this just a matter of this paper, I'd be less concerned, but this is a systematic thing across most of the ABA literature I've read.

It is not ethical to bury your head in the sand in this manner, especially in clinical practice. The fact that past research was not behavior analytic in nature does not give behavior analysts an excuse to ignore it!

Another revealing quote is the following:

... The term motivation, as used here, refers to observable characteristics of a child's responding. An improvement in motivation is broadly defined as an increase in responsiveness to social and environmental stimuli (R. L. Koegel, Carter, & Koegel, 1998). For example, characteristics reflective of motivation include increases in the number of responses a child makes to teaching stimuli, decreases in response latency, and changes in affect (e.g., interest, enthusiasm, happiness) (R. L. Koegel et al., in press).

This is not, by any reasonable definition, what motivation is. Motivation is an internal variable; what that list includes are signs of it. Behavior analysts have often been accused of denying the existence of the mind. Items like the above are a large part of why.

Perhaps even more revealing, however, is the opening of the next paragraph:

Traditionally, interventions for children with autism did not consider these characteristics and how they may have covaried with the actual intervention goal, thus limiting the effects of such approaches. Additionally, disruptive behaviors seemed to be at lower levels or absent and greater generalization occured when motivational variables were incorporated (R. L. Koegel et al., in press).

In other words, older interventions didn't pay any attention at all to the child's happiness, interest, or enthusiasm. They didn't care about that. They didn't even look into ways to minimize boredom as an ethical issue.

The thought -- or lack thereof -- involved makes me so incredibly sick that I cannot even begin to describe it.

Also, note the dates of those citations. Behavior analytic research into autism treatment has been going on since the '60s.

Now... what does paying attention to these things look like?

These variables include the use of child choice, frequent task variation, interspersing previously learned tasks with new acquisition tasks, using less intrusive prompting, reinforcing the child's attempts, and incorporating turn taking within the interactions.

... yeah. It's worth noting that "child choice" is defined as including letting a kid select the toy he wants to play with.

I don't think I need to say anything else here.

This, of course, is not a complete list of my gripes, and it is true that the ABA establishment is changing. These are all references to older methods -- that is, ones in common use prior to the publication of this paper.

Unfortunately, those older methods are still used today... and that paper was published in 1999.

Functional Analysis

Functional analysis methodology was born out of the understanding that most (if not all - this is debated) behavior has a function. Put another way, people do the things they do for a reason.

Behavior analysts actually realized this back in the 1950s. It wasn't until the '80s, however, that they realized that understanding the function of a behavior could be helpful in treating it.

Yeah. I know.

This was actually a great leap forward for clinical behavior analysis. To illustrate just how much of one, let's take a hypothetical kid. For the sake of argument, we can call him "John". John scores 63 on IQ tests and can't speak. Once upon a time, John stubbed his toe and started crying. Not knowing why his son was crying, John's father reassured him, held him, and generally comforted him through the fit. In time, this became a pattern: every time John cried, his father would come in and comfort him.

John liked being comforted.

It didn't take John long to notice the pattern. Soon enough, he was throwing a fit whenever his father was nearby, trying to entice his father to reassure him.

Eventually, however, his father caught on to what John was doing and stopped responding to his son's crocodile tears. As he became desperate for the attention that he was no longer getting, and not knowing any other way to get it, John intensified his tantrums. During the middle of one of these fits, John bumped his head against a wall. Horrified at the possibility that his son might have hurt himself, John's father ran over and checked him for injuries, generally making a big fuss.

To John, however, this was the attention he'd been so desperately craving!

As such, John quickly learned that banging his head against a nearby object would bring his father running. Eventually, his father, desperate for help, ran to a behavior analyst.

Before functional analysis came along, the behavior analyst would have likely chosen what's called a "punishment approach". Given that this specific behavior falls under the umbrella of what are referred to as "self-injurious behaviors", there's a good chance that the specific approach chosen would've been what's politely termed "contingent electrical stimulation".

In other words, they'd have zapped John with a cattle prod every time he banged his head.

Okay, so it wouldn't always have been a cattle prod. There's actually a pretty extensive, if sadistic, collection of technology for doing this, ranging from SIBIS to the Judge Rotenberg Center's GED series of devices. As a note, JRC seems to have used a good bit of it.

That's not to imply, however, that cattle prods haven't been used. A 1995 study by Mudford, Boundy, & Murray is pretty blatant in illustrating this.

Under a functional analysis approach, however, a behavior analyst would ideally have puzzled out the above scenario and taught John a more appropriate way to seek attention.

And yes, things like that have happened. There are plenty of examples in the literature.

This isn't to say, however, that modern functional analysis methods are perfect. One concern (not, by any means, the only one) is that, as conducted in a clinical environment, they tend to have trouble distinguishing between a behavior's function and any relevant motivating operations.

While the above is fairly heavy on the technical jargon (i.e. "behavior", "function", and "motivating operation" all have specific, technical meanings), the problem is fairly easy to illustrate by example.

As such, let's take a second case - let's call him "Bob". Bob is an autistic boy with normal intelligence but poor communication ability. He is insatiably curious, but has poor communication skills.

Periodically, he sees something interesting. Whenever this happens, he desperately wants to ask his mom what it is... but gets extremely frustrated at his inability to do so. He gets so frustrated, in fact, that he bangs his head against a nearby hard object.

The problem that I mentioned earlier is that most functional analysis methods in clinical use today can't distinguish between John and Bob's cases.

Because of this, many behavior analysts would consider John and Bob to have the same problem. More specifically, they'd consider Bob to have John's behavioral problem... and treat him accordingly.

And yes, contingent electrical stimulation is still used. It's not nearly as common as it used to be, but there are places...


References:

Mudford, O., Boundy, K., & Murray, A. (1995). Therapeutic shock device (TSD): clinical evaluation with self-injurious behaviors. Research in Developmental Disabilities, 16, 253-267.

The Latest and Greatest

As a grad student, I read a lot. In the process of this, I come across a lot of rather interesting material. Some of it's interesting in a good way. Some of it... not so much.

Take, for instance, the concept of derived stimulus relations. In the 1990s, these were the Great New Discovery that behavior analysts were researching. What are they? Well... my book's explanation involves the following:

... subjects in the Steele and Hayes (1991) experiment learned that A1 was the opposite of B3 and C3 and the same as B1 and C1. Testing showed that the subjects then derived that B3 and C3 were the same, and that each of these were the opposite of B1 and C1. When they later learned that the arbitrary stimulus D1 was opposite to C3 during a test phase, they then treated D1 as the opposite and not the same as B3. (p. 234)

Yes, really. That's a direct quote. Grad school textbooks tend to overcomplicate things.

Now... this research does have its applications. For instance, this work let them make the following observation:

A derived stimulus relation based view of language suggests that the event and the description of the event interact bidirectionally with one another. If so, verbal self-awareness will be painful when what is known is painful. For example, a trauma survivor may avoid thinking and talking about the trauma, because the very process of contacting it verbally will bring some of the stimulus functions of the original experience to bear in the description (Hayes & Gifford, 1997). (p. 235)

In other words, people tend to avoid doing things that are painful and talking about painful events in your past is painful because thinking about them is painful.

Joy.

Note the date on that citation, too. The book's citing a 1997 paper.

Skinner published The Behavior of Organisms in 1938. Behavior analytic research has been going on ever since... and its history goes back even further.

In other words, it took behavior analysts nearly sixty years to figure that out.

By contrast, Anna Freud published Ego and Mechanisms of Defense in 1936.

Similarly, the "Great New Thing" in the 1980s was what's called "functional analysis". It boils down to an acknowledgement that people do things for a reason, and that knowing the reason why someone does something is helpful in getting them to do something else instead.

I have my issues with functional analysis methodology, but it was a great leap forward. It's hardly enough, but it's a great improvement and a step in the right direction.

Ethically speaking, we need to take into account things which current behavior analytic theory doesn't even acknowledge as existing. Far too many practitioners of the techniques that ABA has developed tend to forget that.


References:

Hayes, S. & Bissett, R. (2000). Behavioral psychotherapy and the rise of clinical behavior analysis. In Ausin, J. & Carr, J. (Eds.), Handbook of applied behavior analysis (pp. 231-245). Reno, NV: Context Press.