11/08/2013

What can behaviorism actually achieve?

Note: This post was inspired by a fascinating Twitter discussion concerning a recent BBC program on "Challenging Behavior in Autism."  The program focused on a particular school and particular families, but sparked an impassioned discussion on whether ABA (short for "applied behavior analysis") in general can help autistic children.  The discussion covered many of the ethical questions autistic people have raised elsewhere, but it didn't address another important question: how well methods based on behaviorism, like ABA, work in the first place.


Julie and Jack from the BBC film.

Disclaimers:
1)  My knowledge about ABA and ABA research is mostly secondhand, via a combination of: testimony from people who've used it; researchers discussing intervention literature; and behavior analysts, mostly on Twitter, talking about theory and practice. These sources represent a variety of opinions and types of education.  However, I don't know how many of these views of ABA represent "what ABA is supposed to be" and how many...don't.

2) It's not really clear what belongs to the realm of behaviorism in general, what to ABA, and what to specific types of ABA programs.  Thus, when someone critiques an experience they've had with ABA, others will be quick to say, "but all ABA's like that."  It would be helpful if there were some sort of consensus about the boundaries of ABA and other teaching methods based on behaviorism.  In the absence of such agreement, I may guess wrong and draw some inaccurate conclusions.

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Before researchers started teaching great apes language using signs or keyboard symbols, they tried teaching them spoken English words.  In the early 1930's, Winthrop and Luella Kellogg raised a chimpanzee named Gua along with their infant son.  By 16 months, Gua could understand about 100 words, but she never learned to speak them.  In the 1940's, Keith and Cathy Hayes raised a chimpanzee named Vicki in their home.  She could understand a large number of words, and with great difficulty, could mouth the words "mama," "papa," and "cup." [1].  Why did this extensive training--likely both formal and informal--fail?  It turns out that chimpanzees' vocal cords do not permit them to produce many of the sounds in human language.  Researchers stopped training chimpanzees to speak words, because it's impossible to train someone to do something that's outside their behavioral repertoire.

In the case of chimpanzees, humans readily recognize that all the rewards and punishments in the world won't make certain behavior possible.  And that makes sense, if you think about it.  If you offer a reward to someone for a behavior they can't do, they may become frustrated, but they'll never exhibit the behavior and receive the reward.  If you punish them for not producing a behavior that's impossible for them, they may become frustrated or develop learned helplessness because they can't avoid the punishment, but they still won't exhibit the behavior.  Why don't we apply this logic to behavioral treatment for disabled humans?

Behaviorists often claim that their work relies on a model that can ultimately explain all behavior, both for animals and humans.  It works for conscious behavior: if you teach a mouse that it will get a sip of juice if it presses a bar, it will learn to press the bar.  If you teach it that it will get an electric shock if it presses a bar, the mouse will learn not to depress it.  The method also works for unconscious behavior: if you ring a bell whenever you present a dog with food, the dog will start to drool when it hears the bell, whether or not it receives food.  This sort of conditioned learning does work most of the time with humans and animals--but it can only work if two assumptions are true.

First, as we've seen, the behavior must be in the individual's repertoire.  In the case of chimpanzees' speech, the limitations are obvious and unchanging: their vocal cords do not permit, and will never permit, the production of most human speech sounds.  In the case of disabled humans, it may be difficult to tell the difficult from the truly impossible, and the limitations may change over time.   A behavior a child cannot produce at age four may become possible to learn by age six.  A behavior a child cannot produce when hungry, thirsty, tired, and sensorily or emotionally overwhelmed may become possible when well-fed, well-rested, and no longer under stress.  Just because the "possibility" of a behavior is a moving target in humans doesn't mean it doesn't limit what a person can learn at any given time under behavioral (or any other) methods.

Second, the individual must have the ability to control whether or not they produce the behavior.  Sometimes, as in the case of pressing a bar, the control system will be conscious; other times, as with Pavlov's dogs' drool, it will be unconscious.  But if the relevant system doesn't work, all the conditioning in the world won't change an individual's behavior.  Shock the mouse every time it presses a bar, and it may feel miserable, but it will still press the bar.  This problem exists in real life, not just thought experiments: many people with ADHD have real-world difficulties learning from mistakes and feedback, leading to an active line of research on reward processing in ADHD [2].   

Behaviorists don't often consider these assumptions, because they hold true for most people and animals.  But in the case of disabilities, they may not.


Consider the literature on autism, where thousands of trials may be given to teach a single discrimination, e.g. between two words [3].  Why do clinicians not consider that the behavior may be impossible at the moment, and offering rewards and punishments will not make it possible?

Both self-report and clinical reports indicate that autistic people have imperfect control over their own behavior.  They may have difficulty starting or stopping a movement or behavior, even if they wish to.  They may perseverate, continuing a behavior or movement past the point where they wish to stop.  They may even become catatonic--a neurologist's term for unresponsive and unable to move at will.  While the most extreme behaviors resemble patients with neurological disorders, many autistic individuals may have less severe versions of the same difficulties.  Thus, it may be difficult for them to produce a desired behavior or stop an unwanted one, even if they want to obtain a reward or escape a punishment.

For these reasons, I doubt ABA or any other behaviorism-based therapy can achieve what it promises eliminate all the disabilities associated with autism.  (It could, however, teach certain individuals certain skills on certain days, at least theoretically).  But I don't think it can "cure" the disabilities involved in autism.

That said, I think the behavioral approach in general does offer some promising tools to autism families, when practiced ethically.   First, the emphasis on consistency (while it can be learned from other sources of parenting advice) probably comforts children who become anxious in the presence of change.  It's probably less stressful to know what you can expect from parents and teachers.  Second, functional analysis teaches caretakers how to look at a behavior in objective, descriptive terms, rather than the imprecise and value-laden terms we use to talk about others' behavior in everyday life.  For example, how often have you heard a friend or colleague complain about someone being "rude" without telling you what the offender actually said or did?  To actually describe the behavior, one would have to say something like "Barbara said she would come to my party and then didn't show up, without calling me to cancel."  Children can better learn from their mistakes if we tell them what not to do in the future instead of calling them names like "rude" or "irresponsible" or "lazy."  Autistic children are more likely to learn how to greet people if caretakers tell them to "say hello when you come in" rather than "be friendly."

Furthermore, the obstacles that prevent ABA from working probably also interfere with other educational methods.  If a child can't produce a behavior, either at a given time or in general, then they can't, no matter how you try to teach them.  Warmer, fuzzier teaching methods would probably alleviate stress, but that might not always make it possible for autistic children to regulate their behavior. 

And of course, none of this discussion addresses the ethical questions surrounding behaviorist therapies--what skills to teach, who benefits, whether and how to acknowledge even non-ideal forms of communication, and so on.  Here, the methodology might matter less than the practitioner.  I've met ABA therapists who see stimming as valuable and who merely want to teach skills, not make autistic children indistinguishable from the norm.  Clinicians who hold objectionable attitudes towards autism likely exist in all schools of therapy.  Given that research doesn't overwhelmingly support any autism therapy right now, you might as well look for a practitioner who cares about your child and shares your values and goals.

If you're a parent, teacher, or clinician and have used behavioral methods before, how do you deal with the issues raised here?  How well do you think behaviorist methods can work for teaching skills? 

[1] I originally encountered Vicki in the book "Apes, Men, and Language" by Eugene Linden, but the current citation actually comes from Ann James Premack & David Premack's 1972 article in Scientific American, "Teaching Language to an Ape."  
[2] See for example: Marjolein Luman, Gail Tripp, & Anouk Scheres (2010). Identifying the neurobiolgoy of altered reinforcement sensitivity in ADHD: a review & research agenda in Neuroscience & Biobehavioral Reviews 
[3] Michelle Dawson, Laurent Mottron, & Morton Ann Gernsbacher (2008). Learning in Autism.  

8 comments:

  1. Don't take it personally. I have tried writing, starting over at least 10 times. I wonder if anyone, in all honesty, can't say they wish there was a better way. Out of curiosity, I joined an ABA "linked-in" group and all they talk about is taking the test (BCBA, I think), Do you know what area causes the most problems? I had read 80% who fail, do so because of the ethics portion. Isn't that something?

    The thing I can't resolve is the denial of free will. Choice, not ToM, is what makes us human. Choice is how you develop conscience. I'm a good catholic girl. Skinner didn't believe in free will.

    Having said that, it isn't ABA that succeeds in the classroom or home. It is something that can't be measured. The teachers I worked with were very ~tough~, but very ~loving~. Yet at the same time, the best of them said the school used to use shock in the 80's, and that it worked very well in changing negative behaviors. Cruel to be kind...but if a kid is beating his head against the wall until it bleeds, it would be a hard choice for me, I won't lie.

    It's like a schizophrenic test that nobody passes.

    I would love to hear from successful ABA practitioners. I think it is hard to discuss because one has to shut down that part of themselves that punishes in order to see a perceived "greater good". The first thing I learned at the school in the 2 weeks preceding the classroom was jujitsu type moves of how to take down a student without hurting them, or yourself. We all had to practice it on each other.

    Ben was never aggressive or had SIB's. When he was 10 life was miserable because of his perceived "faults". Forgiveness on demand so he could start over, setting up a system so he could understand the degree of how angry his choices would make me, and what cost he would pay, literally was my behavior plan. It made life easy...not the constant trial it was before. I know our kids don't learn "the regular way". I changed as much as he did, though. I'll blog it. It's not the answer, but it was for us. Somebody might want to be bored to death, ha!

    I really believe in you...you have a gentle way of putting it out there without offending others. You think so deeply .


    Oh, yes...bringing out the neurological disorders was outstanding. It reminded me of this. This is a talk given at the IACC meeting on July 9, 2013. The IACC is a government committee composed of autistics, parents, researchers, and gov't headed by Thomas Insel. I know, like me, pictures help you process.

    10:00-10:15 Catatonia in Autism Spectrum Disorders

    Lee Wachtel, M.D.
    Medical Director, Neurobehavioral Unit
    Kennedy Krieger Institute
    http://iacc.hhs.gov/events/2013/slides_lee_wachtel_070913.pdf

    The brain can be vicious to it's owner for reason's we don't know. WE HAVE TO TAKE THAT INTO CONSIDERATION. It is the most unusual brain process I have ever heard of. And it is highly prevalent in autism compared to the general population.



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    1. Rose--first of all, thanks, your comment made my day. Talking about controversial issues without letting my emotional reactions or preconceived notions get in the way takes a lot of effort & I'm never sure if I succeed.

      If it's true that 80% fail the ethics section, that says good things about ABA's ethical standards (they're stringent enough to weed out a lot of people who might do harm), but bad things about a lot of the people who want to go into the field.

      (BTW, I'm inclined to believe in free will too, but it's actually low on my list of reasons for skepticism towards certain formulations of behaviorist philosophy. My philosophical leanings aren't actually relevant, though. A practice can help people, even if based on a philosophy I disagree with in some respects. Plus, in my experience with other Schools like Suzuki music training and Waldorf education, practitioners vary *a lot* in their interpretation of and commitment to their philosophy, so you can't really judge a School based on its philosophy anyway).

      Those jujitsu moves sound incredible for last-resort sort of situations. I wonder if many of the cases of abusive teachers you hear about in the news involve people who *don't* know how to do this sort of thing and in general have no idea how to deal with a meltdown.

      Yes, catatonia is EXACTLY what I was talking about. Thanks so much for this presentation. Even without considering others' reactions, it must be demoralizing to lose that connection between your will and your actions, and not be able to count on your body to do what you want it to do. Of course that affects every sort of teaching, not just ABA. But Ido's description of having to go through repetitive training because his hands wouldn't do what he wanted is heartbreaking, though.http://emmashopebook.com/2013/11/05/more-on-aba/

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  2. Hi, Board Certified Behavior Analyst (BCBA) trained and residing in the U.S. here! It is unfortunate to hear that ABA is so ‘controversial’ in the UK, but it seems to me that many of the criticisms against ABA come from 1) misconceptions about the science and practice and 2) Unfortunate experiences with poorly trained providers who claim to be "doing ABA".

    The first defining feature of ABA is that it is socially significant. This means that rather than targeting responses which are easy to measure, we focus on behavior of importance to society: learning, (adaptive, social, or academic skills), reduction of behavior harmful to the individual or others, increases in safety and productivity in business and industry – the applications of the principles of ABA are numerous, of which autism treatment is but one. But is indeed the consumers of our services who drive the process (or at least, should), and that includes selecting the target behaviors. So the idea that practitioners select the targets is inaccurate, at least for those properly and ethically practicing.

    The author’s main thesis is that ABA may be ineffective in teaching skills to individuals who simply can't learn them. It is inaccurate to say that the skill must be in the individual’s repertoire – the ‘repertoire’ is what the individual has learned. However, we do recognize that it is not just the environment that determines behavior, but genetics as well. So the chimpanzee cannot learn to speak, because it is not physically possible. But humans speak, and do a lot of other things, and unless the individual has a physical impairment that would prevent them from performing certain actions, it is reasonable to believe they can learn them. Now certainly, with intellectual disabilities, what a person can and can’t learn may be uncertain, but it doesn’t mean we shouldn’t try. I wouldn't dare to tell a parent what is impossible regarding their child’s development. A competent and ethical behavior analyst assesses an individual’s strengths, and typically seeks to teach them ways to get what they want from the world first – whether it be speaking, pointing, leading, or the use of signs or picture cards indicating their desire.

    However, the statement that ABA can’t achieve what it promises is troubling, because ethically, behavior analysts can't promise anything regarding outcomes, any more than a doctor can. Statements that ABA “cures “autism are indeed problematic on several grounds, and troubling, and shouldn't be made by competent, ethical behavior analysts. However, we do have over 60 years of research that techniques derived from ABA are effective in teaching important skills to individuals who otherwise have difficulty learning, and that in many cases, these skills result in an improvement in the quality of life of these individuals. So to say that research doesn't overwhelmingly support any autism therapy is grossly mistaken, given that the U.S. Surgeon General has endorsed treatment derived from ABA as empirically validated and effective.

    I applaud the author’s recognition that while some practitioners may be unethical or incompetent, it doesn't mean that all are, or that the application of ABA in itself is faulty. I would encourage anyone interested in the activities of behavior analysts to read our Ethical Guidelines (www.bacb.com/index.php?page=57), which describe in a fair amount of detail our approach to working with individuals to improve their lives through the teaching of skills. Unfortunately for our profession (and field), many of the experiences critics of ABA have encountered have been with persons not behaving ethically, and I would wager these same people may not have demonstrated the minimum competencies necessary for certification by the Behavior Analyst Certification Board (www.bacb.com). Incidentally, this website maintains a registry of certified individuals which consumers can use to find qualified professionals.

    Thank you for allowing me to respond!

    Corey L. Robertson, M.S., BCBA
    www.behaviorguy.com

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    1. Hi Corey, I appreciate hearing from you.

      I'm relieved to hear that ABA practitioners aren't supposed to promise outcomes such as a cure, and are supposed to let families select the targets. I wasn't aware of this. Few of the parents of autistic kids or autistic adults I have encountered, apparently, have worked with the sort of ethical behavior analysts you describe. And while the media is often inaccurate, it does argue for ABA as a cure for autism, and I have yet to see any behavior analysts speak out against this idea. Only autistic people and parents of autistic kids. Perhaps you've done so and I've simply missed it? :)

      In the link presented, Elizabeth Pellicano--a renowned autism researcher--explains much better than I can why ABA can't be considered "overwhelmingly supported by science." The fact that the Surgeon General endorses something, as I understand it, does indicate that it's safe and that nothing demonstrably better has been developed. But, I've read that much of the research that best demonstrates affectiveness used "aversives," which are now considered unacceptable and rarely practiced. Thus, the effectiveness of *current* practice is still being demonstrated. Further, most of the studies have compared ABA to waitlist and similar controls, rather than directly comparing ABA with other approaches. It's for these reasons that researchers such as Pellicano argue ABA has not yet been proven a gold standard treatment. Is this an inaccurate assessment of the research?

      It sounds like a competent and ethical behavior analyst, who does all the things you say, could really help autistic people. It's a shame they *appear* to make up such a small fraction of the field. It sounds like we agree that critics have encountered people behaving unethically, and it would be nice to see ethical behavior analysts speaking out against these discredits to their field, as well as defending the field.

      With regards to what's possible for kids with disabilities--yes, absolutely it's hard to tell what's possible at any given time and what isn't, and it's probably best to err on the side of assuming competence. That said, when a therapist notes it takes over 1,000 trials to learn something very specific or the child just isn't transferring a skill after endless training, shouldn't they consider changing strategy or perhaps working on another skill first that might be more readily learned?

      Best, mosaicofminds

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  4. Our son is in an ABA program now and I've been meaning to blog something about it. I think the "it's abusive" and "it's a cure" factions are both far off from our experience.

    Our experience is that it's basically just individualized 1-on-1 teaching and consistent parenting. Our son has lots of fun with it (he likes the attention).

    We've found that the intensity and individualization are essential to making genuine progress on social skills. An hour of social stories or OT per week is silly-inadequate, even for the mildest autism. With the 20 hour intensive program our son has learned so much, it's just been amazing.

    What we can do in the intensive program is continuously peel the skills onion; find all the dozens-or-more skills our son needs to successfully play with friends and work on them. Whenever he learns a skill, he'll get stuck somewhere else next, so we work on that.

    I think the specific teacher might matter a lot more than supposed methodology. Kinda true for any teacher, not just autism specialists. The teacher can be smart or not so much, experienced or not so much, respectful of the child or not so much, able or not able to make a connection, ...

    If there's something I worry about it's intrinsic vs. extrinsic motivation. But sometimes someone with behavioral training can be more conscious about this problem than someone without expertise. It is easy for an untrained person to ACCIDENTALLY administer punishment or build a dependence on external rewards, while in theory a behavior expert can carefully avoid even accidental punishment, and consciously work toward generalization and intrinsic motivation.

    Whether a specific behavior expert successfully does that with a specific child, really comes down to their skills, talents, and motivations.

    In many cases our ABA team is better at relying on intrinsic rewards (keeping the learning fun, etc.) than we are as parents.

    For example our parental attempts to encourage eating vegetables are usually unskilled naked bribery ("eat the spinach and get ice cream") while the BCBA would work hard to get rid of the ice cream. I think a BCBA can be a lot better at this than your average random teacher or parent.

    An ABA program does not need to rely on crude operant conditioning and can look at behavior in a more sophisticated way.

    The historical behaviorist vs. mentalist debate was one with very crude, definitely-wrong visions on both sides (Freudian mentalists, Skinner-type behaviorism). I think behavior analysis has come a long way in sophistication since then, but it retains a skepticism about mentalist speculation about what's happening in someone's head. Given our almost total ignorance of autism right now, and the likely wrongness of any generalizations we might make, the inclination to track and look at the individual data for an individual kid makes lots of sense.

    ABA doesn't rely on a particular diagnosis or particular theory of autism. It just says let's try things and see what works. A creative ABA tutor should be able to come up with a lot of things to try.

    The research does say that not all kids are "responders" and nobody knows why. Some introspective accounts bring up apraxia-like problems (not being able to control the body). I don't see how ABA could help solve that, but not all autism involves that. ABA is just teaching and practice.

    For me the key reason it works is that it's individualized and intensive. Secondarily, the teacher has some training and experience that allows them to accurately understand what might be encouraging a behavior, and try a range of different strategies.

    Nothing else we could find in our city, besides the ABA program, really even tried to teach social skills one-by-one and ground-up. 20+ hours per week is what it takes to really help a child who's having enough trouble to qualify for an autism diagnosis. A couple of short appointments a week won't do it.

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    1. Thanks for sharing your experience and insights. You make a lot of important points. It sounds like your experience of ABA is what it should be. Intensive, individual attention and teaching that's mindful of the unintended consequences of...consequences. :)

      Thanks for pointing out ABA is the only game in town in a lot of areas. Assuming the therapists are ethical like yours, I too would go for ABA over nothing.

      I also think you're right about the need to spend a lot of time learning new skills. A short weekly appointment isn't enough to learn a new language, let alone the social equivalent; you need to practice it every day. Maybe ABA's not the only framework for spending 20+ hours a week on skills--after all, social skills can be practiced in daily life, too--but it has the time expectation built in.

      That's an interesting point that behaviorists are likely to be *more* conscious than others of the problems with extrinsic motivation.

      I'm just curious, have the issues I've mentioned with behavioral control and fluctuating skills from day to day affected your son's progress at all? Do they not apply to him, or does your ABA program just take them in stride?

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    2. Most of the hard questions apply to education and parenting in general I think. For example Alfie Kohn has several books criticizing regular schools and parents of typical kids for using rewards and consequences. Though our BCBA would say (probably rightly) that they do it in a clumsy way.

      I am not 100% comfortable with every decision we make and how we handle every parenting situation, but... what sane parent would be? We keep learning.

      I don't think our son has the control/apraxia issues that people often describe for autism. "Autism" is really many different conditions that all somehow interfere with social relationships. Some people (such as the kid in "the reason I jump") describe it as a sort of control disconnect between mind and body. In my son (and really myself and a couple others in the family) I think it's more like a learning difference. Here is how I think about it for us (mentalist speculation ahead): http://intellectualizing.net/2013/10/23/what-are-intellect-and-instinct/

      It wouldn't surprise me at all if "non-responders" to early education have some kind of fundamental barrier, such as inability to control their actions. This may be a completely different condition from some other autisms. But who knows? Research into autism heterogeneity is inadequate.

      If my son were doing hours of any educational approach and not learning anything, I think we would probably give it up quickly, or at least change the approach. This is one reason it's important to track data.

      For fluctuating skills day to day, I do think my son varies but maybe in the same way anyone would. Didn't eat enough for lunch, didn't get enough sleep, weather sucks, whatever. But if you track data over time you can still see the trend line. If he's getting a lot of "wrong answers" or can't do a skill one day nothing bad happens, they just ask him to try again a couple times and then help him do it with a prompt.

      The big thing for me when thinking about my son is that I went through many terrible years of social cluelessness and isolation myself, and I think that had lifelong consequences. When I looked at the hour of social stories per week or whatever that a lot of high-IQ kids get, there was just no f*g way that was going to make the difference between him playing with friends at school vs. sitting alone. It was also clear to me that he wanted to play with friends and was able to learn but just somehow didn't naturally understand how to play.

      It seems the official definition of ABA is just a list of ways in which it has to be "scientific," plus ethics rules, but not a list of mandated methods. Anything that works - and can be shown empirically to work - counts as ABA. I realize in practice that it's a distinct intellectual tradition and tends to use certain methods, but technically/officially it's this very broad umbrella where the only requirement is to be systematic and based on data. Our team does use a range of methods, some of them are listed here: http://en.wikipedia.org/wiki/Applied_behavior_analysis#Technologies_discovered_through_ABA_research

      I wonder if it might come down to attitude. Are we trying to cure and "fix" a child, or are we trying to help them become their best selves and get the most out of life? Are we pursuing treatment, or education? The details flow from those attitudes. Starting from the right place is everything.

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