Thursday, February 7, 2008

More on ABA

I sat down to write a post a little while ago and ended up going in a different direction than originally intended. Now I'm going to try to get back on track.

ABA is among the least 'contested' treatments for autism. I think this is because it is viewed as being largely benign by most people. This has been my view as well, though there are certainly some compelling criticisms of ABA.

And I guess that's where I am going with this discussion. I want to show you in this post some of the 'good' and then briefly introduce some of the 'bad' of ABA (to be continued at another time) and invite you to comment/decide/consider for yourself where you stand on this issue. If you are the parent of a recently diagnosed autistic child, I'm guessing you may feel differently about ABA than an autistic adult. If you adhere to the idea that environmental toxins played a major role in your or your loved one's autism (I don't), you are less likely to lend credence to this approach as it does not involve detoxification. If you are someone who focuses on scientific method and ethical criticisms (I am, though I'm a layperson in both cases), I suspect you may have a different view than someone who feels the 'early intervention' window will slam shut in a matter of months. You catch my drift, I assume, that ABA undergoes a lot of scrutiny and has lots of adherents and detractors.

I recently had the pleasure of attending a presentation by Dr. Gary LaVigna of IABA on the topic of ABA. Let me continue the philospohical dichotomy I have settled on in this post by saying that Dr. LaVigna said many things that I felt strongly positive about, but the overall thrust of his presentation left me with an uneasy feeling that was not easy to quantify. First I'll relate the good stuff:

Let me begin by saying that Dr. LaVigna is not primarily focused on 'early intervention' ABA. His agency, IABA, according to the content of his presentations, has a focus on autistic young adults and adults who are experiencing very serious problems in any number of areas. These include long-term aggressive/violent behaviors and very challenging self-injurious behaviors. Some of Dr. LaVigna's clients are the types that some people, such as Harold Doherty, would claim have no future outside of an institution. An excerpt from their website says : "It is the philosophy of [IABA] that a person with a developmental disability is entitled to live his or her life with the full dignity of a developing human being, as a self-reliant and productive member of society."

This leads me to the "good" side of ABA. I am familiar with many of the ethical and academic critiques of the ABA method, and I agree at least in part with many, if not all, of them. But there is an aspect of ABA which, in my view, is not directly in the line of fire of that criticism. I am referring to the following (loosely paraphrased) 5 goals of Dr. LaVigna's approach to behavioral supports for autistic individuals:
  1. Community presence and participation that are appropriate and valued by society.
  2. Autonomy and self-determination through the exercise of increasingly informed choice.
  3. Continuous involvement in the ongoing process of becoming independent.
  4. Increasing independence and productivity, to the point of economic self-sufficiency.
  5. The opportunity to develop a full range of social relationships and friendships.
(Note: These 5 items are excerpted from an otherwise-established set of ABA goals/principles which Dr. LaVigna mentioned, but I failed to write down. I am hoping someone with a more encyclopedic knowledge {Alyric? Michelle? Jypsy? Amanda?} of the concept may comment and advise me of a more direct source of this information.)
Now, it is important to grasp that this goal set is certainly not exclusive to ABA as an approach. This set of 5 goals, however, could be applied to virtually any technique and would remain admirable regardless, in my opinion. This set of goals seems to me to be a good beacon of orientation for working towards the happiness and well-being of autistic adults. Notice the lack of emphasis on "reducing/eliminating autistic behaviors" or causing the client to strive to "become indistinguishable from his/her peers" and using that as a measure of success. None of those concepts are discussed or referred to . Instead, a sense of community, a sense of responsibility, the building of meaningful relationships, and true self-determination are discussed. I think that is highly appropriate. And, again, if you refer to my last post on ABA, I believe that a well-intentioned person or group of people who have appropriate goals in mind and value the autistic person they spend time with can have a positive impact in numerous ways that may not be measurable in terms that translate well to research studies (the reverse, unfortunately, is sadly also true).
Here is the other thing about Dr. LaVigna's approach that I found to be good. And you'll have to forgive me for giving the Cliff Notes version, as I spent more time listening than taking notes and therefore can't easily reconstruct precisely what he was saying. But this has to do with, again, self-determination. I think self-determination is a big issue in ABA. My son is only 6 years old, and therefore of course will not be granted nearly as much freedom of choice as one would grant an adult. This is true for virtually any teaching approach for any population. But I do recognize that as a person grows and develops, more opportunities must be afforded that person to self-determine. The squelching of this basic human right is a travesty and occurs far too frequently amongst autistic people (particularly in institutional settings). There are those (again, like Harold Doherty) who believe that institutions are very appropriate for many people, for those who are simply 'beyond help'. I disagree, and therefore applaud Dr. LaVigna's focus on this issue. Briefly, Dr. LaVigna 'indexes' his clients' activities on a matrix. The matrix is categorized into at-home and community settings, with further divisions to specify functional (such as errands) vs. social situations. As a measurement of success (in other words, 'success' cannot be achieved without...), the client must gradually increase his/her involvement in choosing/avoiding/specifying activities (I don't like that word, but have no other to use in its place) to the point where they are at 100% self-determination.
And, really, this approach is one embodiment of ABA. Dr. LaVigna tries to understand what the individual's obstacles to success are (functional behavioral analysis) and then tries to implement (Apply) a plan to achieve the goal of helping the person overcome those obstacles.
I may seem to someone reading this post to be a huge fan of Dr. LaVigna. That's not necessarily the case at all. I am extracting some of the things he talked about and using them as a theoretical model for how, in my opinion, ABA can be used as a method to positively impact the lives of autistic people. Some things he described really resonated with me as being appropriate and logical and of great potential benefit.
But my comfort level with anyone's application of ABA techniques or principles will always be tempered by some of the serious, valid problems with the approach. Problems such as;
Are the goals always met and, if not, what then? Is the functional behavioral analysis likely to be correct? Is 'non-aversive' really not? Will Discrete Trial Teaching create robotic little autistic people? Is the whole thing a colossal waste of time? What do research results tell us? These are some of the potential negatives, and deserve as much attention as the aspects that I perceive as being good.
In my next post on ABA, I will get into some of those issues.

I'd also like to recommend some further reading for those who are interested.
First, a recent ( as in yesterday) and excellent commentary from Sharon on ABA in Ireland.
For an in-depth look at ethics and ABA, please read Michelle Dawson's The Misbehaviour of Behaviourists.
And this excellent essay by Phil Schwarz.

15 comments:

Alyric said...

Steve as one interested lay person to another, Lavigna seems to be indulging in some sleight of hand with the description of his behaviorist approach. Taking a quick look at his descriptors:

>1. Community presence and participation that are appropriate and valued by society.<

He doesn't have to come right out and attack stimming, lack of eye contact and narrow interests because they would be classified as not appropriate by society and would not be valued by society. It is a basic tenet of any kind of behaviorism that the behaviors to be fostered or made extinct are governed by the majority rule. This is the legacy of Jamesian Pragmatism that underwrites all behaviorism. There is no such thing as an individual (what would be commonly meant as such) for a behaviorist.

>2. Autonomy and self-determination through the exercise of increasingly informed choice.<

This is meant to allay criticism but if as a behaviorist he uses reinforcement as a regular constituent of his approach, then there is no belief in autonomy. Autonomy implies free will and this is incompatible with the central claim that people are products of a reinforcement history. Otherwise their free will might come to life and wreck the whole behaviorist explanation for whatever it was that happened seemingly out of the blue. Naturally self-determination doesn't exist either. What happened is the product of external influences.

>3. Continuous involvement in the ongoing process of becoming independent.<

Well they are certainly involved but only as the object of someone's reinforcement schedule and the behaviors they designate as the ones that matter.


>4. Increasing independence and productivity, to the point of economic self-sufficiency.
5. The opportunity to develop a full range of social relationships and friendships.<

These are wish list type statements and you'd probably find them in everybody's advertising package.

Daniel Dennett's 'Skinner Skinned' (available on line through Google books) is worth a read to get a handle on the inadequacy of behaviour modification approaches particularly to learning. If you ever wondered why behaviorist approaches had such a history of being bad at promoting generalisation, it's quite likely that it's the method not the clientele. There is no behaviourist explanation for why any concept should generalise and since they earnestly teach the children in many situations in the fond belief that this will fix the generalisation problems, the blame for this not working will be laid on the autism - naturally. Couldn't have anything to do with the artificiality of the approach - Nah, 'course not.

Alyric said...
This comment has been removed by the author.
LIVSPARENTS said...

I dunno, I think that ABA may be much maligned because of it's shady past. It really all boild down to how good your therapist is.

Do we discount all psychiatric institutions because some are atrocious? No, we learn why they are bad and look out for those symptoms. Same with ABA. People like Michelle Dawson rightfully point out that there were and are serious issues with some practices and practitioners of ABA. But while I hope and pray that it wasn't true; Mr Doherty is probably right to say that there are autistic people who may be beyond our abilities to help. Not because we are using the wrong therapies, but because there are other neurological issues involved or because the way to 'reach' them has not been figured out yet. You can't fault him for advocating for a viable approach such as ABA in these situations, even though he may be throwing too broad a blanket on the rest of the autistic population from a perspective POV...

Joseph said...

ABA is an interesting case of a therapy supported by mainstream scientific authority, which does not have enough of a scientific foundation.

I wonder why Harold hasn't shown up yet to remind us that the American Academy of Pediatrics, the Surgeon General of the United States, and so on, have said that ABA is wonderful.

That's why I don't generally like to use arguments from authority, or "bad journal" types of arguments. It's better to discuss the actual merits of the data that exists. When it comes to ABA, the fact remains that the study with the best methodology to date, the one that was supposed to address prior criticism, was largely unsuccessful. Whereas ABA hype mostly originates with one study that has multiple demonstrable errors.

Steve D said...

Alyric -
Excellent comments, thank you.
Re #1, having met they guy brioefly I don't think this is what he had in mind. He seemed far less concerned with stimming and more concerned with things like aggression, clearly dangerous activities (to self or others) or inappropriate grabbing (in one specific case he mentioned). He talked about helping a person to mitigate these behaviors which had become real barriers to participating in society. Things like stimming and eye contact were not even on his radar screen during this presentation.
Re #2 and #3 I agree and disagree. As a parent, I am a 'behaviorist' from the standpoint that I reward good behavior and punish bad behavior. The goal seems to me to be a orimary determining factor fo the 'rightness' or 'wrongness' of this approach. (Plus a whole slew of other considerations as relate to my clumsy analogy). So, where do we draw the line between helping someone to integrate into society versus trying to protect their rights/needs as an individual?
#4 and #5 - You are right, and that agrees with my point that these are admirable goals. They may be 'vanilla' but they are better than some alternatives (such as 'indistinguishable from one's peers').

Steve D said...

LP - Thanks for your comments (nice to see you here).
My issue with Harold Doherty's belief system is a little different than what you are implying. He is entitled to his opinions, but I disagree with many of them.

Steve D said...

Joseph, I agree that it is good to discuss the merits of the data, but I also think we are dealing with people here and that to only focus on the data, as it were, would be an error in judgment.
The scientific criticisms are valid and cannot be ignored. But I think, as I have said, that there is some good to be taken away from ABA and some lessons to be learned from it. I guess that's my point.

Michelle Dawson said...

In a well-designed multi-site RCT, Tryer et al. (2008) showed that placebos were dramatically effective in reducing "aggressive challenging behavior" in developmentally disabled adults. Some of the adults were autistic; there was no difference in the dramatic effectiveness of the placebo in autistics vs other developmentally disabled people.

The dramatic effect of the placebo was rapid and sustained for 6 months (the intended follow-up period).

This is why good experimental design exists, and the authors of Tryer et al. (2008) take the trouble to argue that developmentally disabled people deserve to benefit from and be protected by recognized standards of science.

This is one of the major things I go on about.

So that would be at least part of my response to Dr LaVigna (who is unsurprisingly enthusiastic about the services he provides).

Also, there is no doubt that a lot of autistics are written off. But I disagree with Bill and with Mr Doherty that some autistics just naturally are write-offs. More plausibly, autistics who are written off have very difficult outcomes, but this would be true of all human beings who are written off.

LIVSPARENTS said...

I'm having trouble formulating my argument, because, just as a person stuck on the wrong side of an argument on a debate team, I'm having trouble defending things I don't quite beleive in, but here it goes.

I know we can have societal ideals, societal goals and societal realities. Societal realities are that there are societal constraints. The ideal would have every potential 'write off' get every available and up-to-the-minute therapeudic, medical and 'social' intervention known. The reality, as we know, is we are lucky if we provide one or two of the three. Most will receive subpar services, resulting in subpar abilities to integrate or even function in society. (I was going to use a sociopath as my analogy next but thought better of it.)

What if you are dealing with, say an artist with superior abilities in their chosen artistry, but cannot find a way to turn his/her talents into a means of support? It's society's shame that this person's talents cannot be supported by society. But is it society's RESPONSIBILITY to nurture them as they are, or maybe the responsibility is just to get them to a point where they can support themselves through means other than using their ideal talents?

It's a cold cruel reality out there we live in, especially when dealing with individuals where society has failed them. Truth is, we should all have the ideals in our hearts, the goals in our minds and the realities in our rear view mirrors...

I hope my daughters have Michelle's idealism when she grows up BTW...

Do'C said...

Hi Steve,

I enjoyed this post. I have to say, I thought Dr. LaVigna's presentation was interesting, but not because of the content - more because of his responses to the audience. I know he was probably irked by my inclusion of ABA in the list of "autism treatments" that are not scientifically proven - he commented and asked about that.

On the other hand, I thought he was flexible enough and open minded to accept that he should change his language about a person not completing a task by stating, "Joe wouldn't do it," to, "Joe didn't do it," the latter which is less indicative of intention or blame in the eyes of many.

I was irritated by one of his statements during the "Ambassador's for autistic people" discussion, when he stated that it's important to be ambassadors for parents too. Wrong time. Wrong place. Not an ambassador at that moment, at all. Harold probably would have cheered gleefully.

Alyric said...

Hi Steve

About this "But I think, as I have said, that there is some good to be taken away from ABA and some lessons to be learned from it. I guess that's my point."

Sorry, my point is that philosophy matters and the points I made were strictly about LaVigna and not about ABA as practiced. What you do and how you do it is the product of what you believe and it just so happens that if you claim to be doing ABA and use reinforcement schedules and say that what you're doing has an empirical basis, yada yada then there are certain beliefs involved in that, notably that there is no such thing as an autonomous person. The latter point is crucial by the way because the great arguments against utilitarian ethics - person good as long as useful and that what society deems valuable as being prima facie valuable is that there is an autonomous person whose value rests almost entirely on the fact of existence, period.

I doubt that there are many therapists who actually practice any kind of ABA, not really. Gina Green would of course but I'd think that they would be a tiny minority and nothing wrong with that at all - except that they have no empirical basis for what they're doing - at all. But then, who does? As far as I can see, there is not one intervention out there that is anything but 'hard sell' plausibility.

Your point Steve is that ABA as you know it has some good things. With good hearted therapists and they wouldn't be in this field unless they wanted to be - it's not an easy career option, there's bound to be lots of good things, like structure and breaking down motor tasks into realiseable components and all that sort of thing. But those tactics weren't dreamed up by ABA therapists, even if they were co-opted by them.

There are lots worse interventions than ABA in my book. Positive behavioral support and errorless learning make my blood run cold. RDI is a joke. Take a look at the Hanen method (TM). It's a perfectly good concept and should actually be a part of what folks do in general but on it's own - trade-marked and all? Somebody saw a bit of evidence and thought of a way to make a buck - it's an ethical wasteland.[/rant]


I'm still going to write a ramble about the 'perfect intervention' -my little fantasy about what intervention currently available would be able to incorporate without too much difficulty some of the perception/learning things we know about autistics. That's currently none, IMO but there's some hope.

Alyric said...

Hi Steve

About this "But I think, as I have said, that there is some good to be taken away from ABA and some lessons to be learned from it. I guess that's my point."

Sorry, my point is that philosophy matters and the points I made were strictly about LaVigna and not about ABA as practiced. What you do and how you do it is the product of what you believe and it just so happens that if you claim to be doing ABA and use reinforcement schedules and say that what you're doing has an empirical basis, yada yada then there are certain beliefs involved in that, notably that there is no such thing as an autonomous person. The latter point is crucial by the way because the great arguments against utilitarian ethics - person good as long as useful and that what society deems valuable as being prima facie valuable is that there is an autonomous person whose value rests almost entirely on the fact of existence, period.

I doubt that there are many therapists who actually practice any kind of ABA, not really. Gina Green would of course but I'd think that they would be a tiny minority and nothing wrong with that at all - except that they have no empirical basis for what they're doing - at all. But then, who does? As far as I can see, there is not one intervention out there that is anything but 'hard sell' plausibility.

Your point Steve is that ABA as you know it has some good things. With good hearted therapists and they wouldn't be in this field unless they wanted to be - it's not an easy career option, there's bound to be lots of good things, like structure and breaking down motor tasks into realiseable components and all that sort of thing. But those tactics weren't dreamed up by ABA therapists, even if they were co-opted by them.

There are lots worse interventions than ABA in my book. Positive behavioral support and errorless learning make my blood run cold. RDI is a joke. Take a look at the Hanen method (TM). It's a perfectly good concept and should actually be a part of what folks do in general but on it's own - trade-marked and all? Somebody saw a bit of evidence and thought of a way to make a buck - it's an ethical wasteland.[/rant]


I'm still going to write a ramble about the 'perfect intervention' -my little fantasy about what intervention currently available would be able to incorporate without too much difficulty some of the perception/learning things we know about autistics. That's currently none, IMO but there's some hope.

Steve D said...

Someday, Alyric, you and I could sit down and have a long talk about this stuff over a cup of coffee. I would really look forward to that.
In the meantime, let me just say that you captured my thoughts very well when you said:
"Your point Steve is that ABA as you know it has some good things. With good hearted therapists and they wouldn't be in this field unless they wanted to be - it's not an easy career option, there's bound to be lots of good things, like structure and breaking down motor tasks into realiseable components and all that sort of thing. But those tactics weren't dreamed up by ABA therapists, even if they were co-opted by them."

Yes, that's my point - that there is some good. And that ABA is not required to do the 'good'. But also that ABA provides a framework in which the 'good' such as breaking down tasks for improved teaching are systematic as opposed to random.
And, again, I am slipping away from the real definition of ABA and instead using the support provided to my son under the name of ABA as my point of discussion.
Ah, well, this is a complex issue and it takes some ironing out of definitions and whatnot as we go.

Steve D said...

Hi Do'C -
I specifically recall what you are referring to, and it is worth mentioning here.
He was into an anecdote about someone who was not eating. He, in describing this person, said very frankly, "He wouldn't eat".
Anne Donnellan interrupted him and said, "Actually, Gary, you probably mean to say 'He didn't eat'. Saying 'wouldn't' implies something that's not necessarily true."
Dr. LaVigna thought for a moment, then agreed to change his language.

It was a very interesting exchange, in a good way. Its nice to see someone who is willing to listen and learn, particularly when they are supposed to be the teacher in a given scenario.

Sharon said...

I've enjoyed reading this post and the discussion.

It really does seem to me that ABA provides mainly, as Steve said, "the framework in which the 'good' such as breaking down tasks for improved teaching are systematic as opposed to random."

In that case, why have ABA at all, why not just call it what it is, teaching?

In ordinary schools, the teaching methods used vary, but they aren't labelled the way teaching seems to have to be for autistic children. Why is this? Why can't the children all have their individualised education plans drawn up, saying whether they seem to learn best in a highly structured environment with a dedicated teacher, or whether they do best with a lot of self directed learning using videos, books and computers freely or whatever.

I can see that in some places, the ABA name is already in place and while the therapists have adopted all the better, non-aba teaching systems, it's probably hard to change the status quo, especially regarding funding. I do think it is worth questioning why they are trying to sell ABA as the one-and-only-way for autistic children here in Ireland.

Alyric, I'd never thought about Hanen as a trade-marked method, but I can see that it is now you mention it. I have their 'More than words' book and thought it contained lots of sensible and nicely presented advice for parents of young and particularly non-verbal autistic children. It's fine to use in that way, not to base some sort of 'therapy programme' on.

I'd not heard of Dennett's book on Skinner; I'd like to read it, so thanks!