Translation by Hunter Mclean
Introduction
First of all, this text focuses exclusively on the ABA / ICI method: Applied Behavior Analysis / Intensive Behavioural Intervention. ABA / ICI is part of Cognitive Behavioral Therapy (CBT) and as I wrote in another text [1], some CBT interventions have proven effective in autistic people. So, remember: this text deals with ABA / ICI only.
I also want to make it clear that this text is about the method and not the people. In no case does this mean that caregivers, professionals or parents are incompetent or disrespectful of children with autism. I deeply believe that the main motivation that guides them is that of offering and providing help and support to the autistic person. Thus, I repeat, this text is not meant to be a critique of people, but of the method.
This text is based on several articles and books [2], [3], [4], [5], [6] to which I add my comments and reflections. To deepen the subject, I invite you to read these articles and books.
What is it?
So let’s start with a brief history. Where does ABA / ICI come from? The creation of this method is recognized by Dr. O. Ivar Lovaas, who was the first to apply applied behavioral analysis, behaviorism, to children. His method uses a process: demand-action-reaction. Thus, the worker makes a request, the child acts and the responder reacts according to the action of the child. When the child responds adequately to the request, the child is rewarded. If the child does not respond properly, he or she is punished. The means used to punish the child are shouting and slapping, techniques that are, to say the least, aversive. Punishments are used until the desired response is obtained [7]. The results show that 47% of children (9/19) who received intensive therapy (40+ hours per week) returned to normal functioning after 2 years, and completed their first year of regular school without any specialized educational support [8] .
Dr. Lovaas’ study is the basis of all other ABA / ICI studies. From this study comes all the justifications for the use of various aversive techniques such as electric shocks, physical violence such as slapping, pinching, pulling hair, using harmful odors or toxic liquids, etc. in different studies or interventions [9].
Dr. Lovaas’ study raises important reflections on ethics and methodology with aversive behaviors and results (47% success and 53% failure). Let’s first look at the positions for and against the method.
Arguments for ABA
Although several courts, Canadian and American in particular, and health organizations such as the High Authority for Health (the French health authority) [10], [11], [12] have ruled against the use of aversive techniques, some behaviorists still advocate these aversives used in the ABA / ICI method.
« If the child fails to respond to a request, a ‘blower’, sitting behind the child, uses a guidance, with increasing intensity, until he gets the answer. Physical guidance is used to correct the individual’s mistake or non-compliance. « [13]
We can also read: « Ms. Vinca Rivière, founder of the Camus Experimental Center in Villeneuve-d’Ascq, which she presents as a pilot site of the ABA method, does not hesitate to state in 2012 what many behaviorists persist in thinking. She said to a Mediapart journalist, « In behavioral analysis, there are electric shock punishment procedures. » [14]
In another study [15], stakeholders were interviewed to understand the rationale for using aversive techniques and the impacts of their use on them. According to this study,
« The authors conclude: « allowing staff members to use a wide variety of types of interventions, including strong aversive techniques, can reduce their work stress and enhance their sense of effectiveness. » The educators consulted consider that strong aversive techniques applied to autistics make it possible to obtain the best results. […] [Dr. Lovaas] would have agreed in a discussion with [Dawson] in 2003, frankly conceding that getting the same results without resorting to aversive techniques would be much more difficult. « [16]
Arguments against ABA
« We have witnessed, » they add, « circumstances in which » professionals « have abused the punishment to a point that is considered to be mistreatment ». Moreover, they note that it is too easy to use and that it is used too often « emotionally » so that its « incorrect use » may negatively affect ABA’s reputation. The mention of « improper use » of punishment in a domain that explains the reasons for its end is important: it reveals that the notion of correct punishment persists in the logic of the method. « [17]
Thus, according to some behaviorists, there is a correct use and incorrect use of aversive techniques.
Dr. Smith, a director of the Northwest Young Autism project, in his testimony in Auton et al. v. AGBC [18] indicates that he has identified 15 locations in different countries that replicate the Lovaas model. He notes that no center is taking up the Lovaas ABA / ICI experiment and that duplicating this experience would be difficult or impossible for two reasons.
First, it would be difficult to have parental consent for a control group because the ABA / ICI opportunity period would likely be closed after the child’s participation in the control group. In other words, the parents would not consent to their child’s participation in the control group knowing that the intervention is effective at a very young age, 2-4 years, and that when the experiment is completed, the child of the the control group would be too old to benefit from this intervention.
Second, Lovaas used aversive techniques like slapping. However, it is generally accepted that the current method does not include and should not include aversive techniques [19].
Finally, we must not forget that Lovaas, in 2003, himself confirmed to Michelle Dawson, that it was much more difficult to obtain the same results without the use of aversive techniques [20].
My Opinion
As a human being, autistic, and parent, I am against any physical punishment inflicted from the perspective of education or intervention with any child or person.
I denounce the ABA / ICI method and my argument is based on the evaluation of the results of the Lovaas study according to methodology and ethics.
Methodology
« As any scientist knows, random assignment is an essential element of scientific credibility in treatment studies » [21].
Several analysis reports demonstrate the weakness of the methodology used in existing studies of interventions with children with autism.
The New York State Department of Health Guideline for Assessment and Intervention of Young Children with Autism / Pervasive Developmental Disorder report shows the shortcomings in assigning children and parents as well as control groups. Completed in 1999, it presents an analysis of all studies that refer to an intervention or educational approach for autistic children.
The department has identified 232 articles on the subject. Of these 232 research articles, only 5 articles, including 4 research papers, meet the New York State Department of Health Clinical Pratice Guideline’s scientific demonstration criteria. Thus, only 4 studies have proof evidence. [22] However, none of these 4 studies has a random assignment of children, ie these studies have no control group compared to a group receiving the intervention. 3 studies had a control group, but the assignment of participants was done according to criteria decided by the researchers, including for practical reasons. Thus, there was no random condition. [23] This therefore rejects « the essential element characteristic of scientific credibility in treatment studies ».
For its part, the Scientific Review article of Mental Heatlh Pratice (2002) states that the methodological weakness of existing studies severely limits the conclusions that can be drawn about the effectiveness of interventions. The article also notes that no study used a true experimental methodology in which subjects were randomly assigned between the treatment group and the control group. [24]
Added to this is an editorial by Herbert and Brandsman that Dr. Lovaas’ experience did not randomly assign participants between the treatment group and the control group and that this methodology raises important questions regarding results related to the selection of participants for each group. This bias is demonstrated by the differences between the control group and the treatment group prior to experimentation. This has the effect of limiting the conclusions that may emanate from this study. [25]
In 2000, Dr. Smith, Groen and Wynn released the first truly randomized study of intensive behavioral interventions at a young age. Unlike Dr. Lovaas who used only the IQ and the school integration criteria, they used several important evaluation criteria related to child development (intelligence, academic achievement, language, social behaviors and functions, adaptability and emotionality). Thus, they wanted to eliminate two possible biases related to Dr. Lovaas’ results. First, the increase in IQ could be due to test compliance rather than actual cognitive development.
Second, school attendance may reflect more the parent’s advocacy processes for their children or differences in school-specific policies than a real effect on the autistic child. [26] In their study, the group assigned for treatment received an intervention based on the model of Dr. Lovaas, while the control group, as for the study of Dr. Lovaas, had only the intervention of the parents.
The children were a similar age of 24 to 43 months and the intervention lasted at least 2 years. Nevertheless, the results were dramatically less significant than for the study of Dr. Lovaas. In fact, only 13% of children met Dr. Lovaas’ criteria. In addition, there was no difference in behaviours and behavioural, coping, and emotional functions. [27] Thus, the only scientifically valid study up to the year 2000 did not demonstrate the effectiveness of the Lovaas methodology.
Ethics
According to the first article of the United Nations Convention against Torture and Other Cruel, Inhuman, or Degrading Treatment, torture is defined as follows:
“For the purposes of this Convention, the term « torture » means any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining from him or a third person information or a confession, punishing him for an act he or a third person has committed or is suspected of having committed, or intimidating or coercing him or a third person, or for any reason based on discrimination of any kind, when such pain or suffering is inflicted by or at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity. It does not include pain or suffering arising only from, inherent in or incidental to lawful sanctions”
In other words, when pain or suffering, whether physical or mental, is intentionally inflicted by a person acting in a professional capacity, on grounds of discrimination such as disability, this is torture unless that the sanction is legitimate. By legitimate sanction, it is possible to think of the imprisonment of a person for a crime or the suffering caused by a medical operation when this intervention is the only possible solution. But ABA / ICI and more specifically, the use of aversive techniques with autism is a legitimate sanction?
To avoid dealing with the ethical question of the use of aversive techniques, several behaviorists claim that aversive techniques are not useful for the intervention to be effective. The same results could be reproduced without the aversive techniques.
This statement raises two fundamental questions: first, what is the basis of this statement? and the second, and if that statement was true?
Use of aversive techniques vs. effectiveness of the ABA / ICI method
Previously, I presented the results of the study by Dr. Smith et al [29], the first researchers to have done a randomized study on ABA / ICI. Dr. Smith justifies the difference between his results and those of Lovaas, precisely because of the absence of aversive techniques in his reproduction. [30]
In addition, Dr. Lovaas himself acknowledged the use of aversive techniques and that the use of slapping was the most effective technique to eliminate these behaviours. And we must not forget that in 2003, he confirmed to Michelle Dawson, that it was much more difficult to achieve the same results without the use of aversive techniques.
The failure of the ABA / ICI method, without the use of aversive techniques, goes well beyond the assumptions of Dr. Lovaas and Smith. Indeed, in 2012, France, with its Plan en autisme, decided to create 28 experimental structures to implement the ABA intervention. Thus, 578 children will be followed for 5 years, in optimal conditions: ratio 1.03 child / interventionist, and material and logistical resources without constraint for the proper application of the intervention.
After two years of interventions, the vast majority of parents (80% of parents in 24 structures and between 43% and 79% of parents in the other 4 structures) noticed progress. However, these advances are at the level of language, cognition and so-called problematic behaviors. Progress is significantly less for adaptation, the level of autism and social functioning. [31]
However, as stated by the authors of the report, the success reported by the families must be nuanced. The placebo effect is an important factor in itself, since the families wanted to have this service. In sum, the mere fact of being accepted into the structure is a success for families. [32] On the other hand, while the criterion of social inclusion is more appropriate for assessing the different capacities of the autistic child, on this criterion, only 3% of children have integrated a so-called ordinary class at school level, and of this 3%, no information is available on whether these children continue to have help from a resource person at school or whether the child continues to receive different interventions. [33]
The conclusion is clear. 3% success … ABA / ICI gives no result superior to the intervention of the parents.
Finally, it is obvious that any child, in a 1 for 1 frame, will develop their cognitive abilities, their language and change their behavior. This is called development. A development that also exists in autistic children.
The assertion of the behaviourists must therefore be rejected since no scientific demonstration proves it, and even the creator of the method rejects the idea of similar results without the use of aversive techniques.
The second question is even more disturbing. If it were true that the 47% success of the ABA / ICI method could be achieved without the use of aversive techniques, it would mean that hundreds of children have been physically assaulted for absolutely nothing. This would mean that Dr. Lovaas was striking children deliberately, voluntarily and systematically without the consent of the children.
This would mean that behaviorists voluntarily decided to hurt children when they had other possibilities. This goes against even the definition of a legitimate sanction that can be described as torture according to the definition of the United Nations Convention against Torture and Other Cruel, Inhuman, and Degrading Treatment.
Thus, the proponents of ABA / ICI can not make an affirmation and its contrary. They must choose. They must recognize that Dr. Lovaas’s 47% achievement is a consequence of the use of aversive techniques, which in itself is not ethical and is a demonstration of the acceptance of violence against autistics. Otherwise, they must affirm that there is no evidence of ABA / ICI’s success and that millions of dollars are wasted unnecessarily on acts of faith and belief.
And if the ABA / ICI method was also based on prejudices towards autistics…
Dr. Lovaas evaluated the results of the ABA / ICI method on two criteria: the abolition of so-called inappropriate behaviors and the improvement of the IQ. [34]
The criterion of the abolition of inappropriate behaviors
The behaviors described as unsuitable according to Dr. Lovaas’ research are stimulation, aggressive, and non-compliant behaviors. Thus, it encompasses all the behaviors associated with autism, from characteristic movements to echolalia and specific interests. As mentioned earlier, Dr. Lovaas himself recognized the use of aversive techniques and that the use of slapping were the most effective techniques to eliminate these behaviors.
Thus, we can understand that a child under 40 months (46 months if there is presence of echolalia) regularly undergoing slaps, 40 hours per week, for 2 years, can develop a control of certain behaviors to avoid being hit. 47% have done so, but more than 50% of children will need these aversive techniques unnecessarily, since they will continue to behave inappropriately. More than 50% of children will be mistreated for nothing.
This statistic speaks volumes not only about the failure of intervention maltreatment, but also informs about the nature of autism. Indeed, it demonstrates very well the link between autism and certain behaviours and their importance for autistics. Despite multiple assaults, for two years, 40 hours per week, more than 50% of children did not give up these behaviours. For these children, the requirement to abolish their so-called inappropriate behaviors was more demanding and painful than repetitive slapping.
The criterion of improving the intelligence quotient
Dr. Lovaas’ study states that IQ tests were based on the Weschler assessment scale for children [35]. However, Dr. Dawson, Soulière, Gernsbacher and Mottron have demonstrated that this scale negatively biased the results of autistic people [36]. Thus, in itself, the tool does not make it possible to evaluate the improvement of the intelligence quotient since it does not even evaluate the intellectual quotient of the autistics.
So, what do the results demonstrate? To answer this question, it should be noted that Weschler’s IQ tests are administered orally and require verbal responses for some subsections of the tests. In addition, some sub-sections assess general knowledge and learning that is considered normal by average. So, would this improvement in intelligence quotient not be a demonstration of the effectiveness of aversive techniques for conditioning a person to provide certain answers based on different questions? In other words, is the result not a demonstration of the effectiveness of aversive techniques to turn the person into a parrot? This question is all the more justified considering the importance of oral communication in the administration of these tests.
Again, if you verbally and physically assault a child under 46 months of age, regularly and constantly, 40 hours a week, for more than two years, is it possible for him to memorize answers by heart and repeat the desired response? This increases the success of the assessment test. On the other hand, it has nothing to do with the cognitive development of the child.
In conclusion, all parents are free to choose interventions for their children. But honestly, how many parents would decide to subject their child to the ABA / ICI method if they are told that the method has no effect unless they use aversive techniques? How many parents would agree that the intervention to help their child consists of physical assault?
Revisions and corrections: Claude Filion
[1] https://decouverteaspi.wordpress.com/2018/01/23/lanxiete-les-traumatismes-et-lautisme/
[2] Maleval J-C. et Grollier M., Actualité de l’évolution de la prise en charge des enfants autistes. De ABA à l’Affinity thérapie, http://www.autistes-et-cliniciens.org/Actualite-de-l-evaluation-de-la-prise-en-charge-des-enfants-autistes, consulté le 20 avril 2019.
[3] Dawson M., The misbehaviour of behaviorists, Ethical challenge to the autism-ABA industry, http://www.sentex.net/~nexus23/naa_aba.html, consulté 20 avril 2019
[4] Mottron L, L’intervention précoce pour enfants autistes : Nouveaux principes pour soutenir une autre intelligence, MARDAGA, juin 2016, p.304.
[5] Davidson, S., Does ABA harm autistic people?, https://autisticuk.org/does-aba-harm-autistic-people/?fbclid=IwAR2tN7vtWOwuc9uGe3iAvvddm-O3UQlk-LkgtBLPXdeTjlOxv8pRQObB2I0, consulté le20 avril
[6] M. A. Gernsbacher, Is one style of early behavior treatment for autism “scientifically proven”?, http://www.gernsbacherlab.org/wp-content/uploads/papers/Gernsbacher_Scientifically_Proven_JDLD_2003.pdf, consulté le 20 avril 2019.
[7] O, Ival Lovaas, Behavioral treatment and normal education and intellectual functioning in young autistic children, Journal of Consulting and Clinical Psychology, 1987, vol 55, no1, 3-9, https://www.beca-aba.com/articles-and-forms/lovaas-1987.pdf, consulté le 20 avril 2019.
[8] O, Ival Lovaas, Behavioral treatment and normal education and intellectual functioning in young autistic children, Journal of Consulting and Clinical Psychology, 1987, vol 55, no1, 3-9, https://www.beca-aba.com/articles-and-forms/lovaas-1987.pdf, consulté le 20 avril 2019.
[9] Maleval J-C. et Grollier M., Actualité de l’évolution de la prise en charge des enfants autistes. De ABA à l’Affinity thérapie, http://www.autistes-et-cliniciens.org/Actualite-de-l-evaluation-de-la-prise-en-charge-des-enfants-autistes, consulté le 20 avril 2019.
[10] Maleval J-C. et Grollier M., Actualité de l’évolution de la prise en charge des enfants autistes. De ABA à l’Affinity thérapie, http://www.autistes-et-cliniciens.org/Actualite-de-l-evaluation-de-la-prise-en-charge-des-enfants-autistes, consulté le 20 avril 2019.
[11] Dawson M., The misbehaviour of behaviorists, Ethical challenge to the autism-ABA industry, http://www.sentex.net/~nexus23/naa_aba.html, consulté le 20 avril 2019.
[12] Hudon-Friceau A., Le châtiment corporel envers les enfants, toujours toléré?, https://ici.radio-canada.ca/nouvelle/1001346/chatiment-corporel-tolere-au-canada-violence-enfant-fessee, consulté le 20 avril 2019.
[13] Lecestre A. et Keser L., Le modèle de Lovaas/UCLA model/Young autism projet YAP, https://www.ba-eservice.info/loovas, consulté le 20 avril 2019.
[14] Maleval J-C. et Grollier M., Actualité de l’évolution de la prise en charge des enfants autistes. De ABA à l’Affinity thérapie, http://www.autistes-et-cliniciens.org/Actualite-de-l-evaluation-de-la-prise-en-charge-des-enfants-autistes, consulté le 20 avril 2019.
[15] Harris S.L., Handleman J.S., Gill M.J. and Fong P.L. Does punishement hurt ? The impact of aversives on the clinician. Research in Developpemental Disabilities, 1991, 12, pp. 17-24
[16] Maleval J-C. et Grollier M., Actualité de l’évolution de la prise en charge des enfants autistes. De ABA à l’Affinity thérapie, http://www.autistes-et-cliniciens.org/Actualite-de-l-evaluation-de-la-prise-en-charge-des-enfants-autistes, consulté le 20 avril 2019.
[17] Maleval J-C. et Grollier M., Actualité de l’évolution de la prise en charge des enfants autistes. De ABA à l’Affinity thérapie, http://www.autistes-et-cliniciens.org/Actualite-de-l-evaluation-de-la-prise-en-charge-des-enfants-autistes, consulté le 20 avril 2019.
[18] Auton et al. V. AGBC, 2000 BCSC 1142, https://www.canlii.org/en/bc/bcsc/doc/2000/2000bcsc1142/2000bcsc1142.html
[19] Idem par 40.
[20] Dawson M., The misbehaviour of behaviorists, Ethical challenge to the autism-ABA industry, http://www.sentex.net/~nexus23/naa_aba.html, consulté le 20 avril 2019
[21] M. A. Gernsbacher, Is one style of early behavior treatment for autism “scientifically proven”?, http://www.gernsbacherlab.org/wp-content/uploads/papers/Gernsbacher_Scientifically_Proven_JDLD_2003.pdf, consulté le 20 avril 2019.
[22] M. A. Gernsbacher, Is one style of early behavior treatment for autism “scientifically proven”?, http://www.gernsbacherlab.org/wp-content/uploads/papers/Gernsbacher_Scientifically_Proven_JDLD_2003.pdf, consulté le 20 avril 2019.
[23] Idem.
[24] Idem.
[25] Idem
[26] Idem
[27] Idem
[28] Nations Unies Droit de l’Homme Haut-commissariat, Convention contre la torture et autres peines ou traitements cruel, inhumains ou dégradants, https://www.ohchr.org/fr/professionalinterest/pages/cat.aspx, consulté le 20 avril 2019.
[29] Dr Smith, Groen et Wynn, 2000.
[30] Dawson M., The misbehaviour of behaviorists, Ethical challenge to the autism-ABA industry, http://www.sentex.net/~nexus23/naa_aba.html, consulté le 20 avril 2019
[31] Idem.
[32] Idem
[33] Idem.
[34] O, Ival Lovaas, Behavioral treatment and normal education and intellectual functioning in young autistic children, Journal of Consulting and Clinical Psychology, 1987, vol 55, no1, 3-9, https://www.beca-aba.com/articles-and-forms/lovaas-1987.pdf, consulté le 20 avril 2019.
[35] Idem.
[36] Dawson, M., Soulières, I., Gernsbacher, A. M., & Mottron, L. (2007). The Level and Nature of Autistic Intelligence. Psychological Science, 18(8), 657-662. doi: 10.1111/j.1467- 9280.2007.01954.x
À la découverte d'un autiste-Mathieu Giroux 