Wednesday, November 08, 2006

Autism advocacy and aversives (part one)

In Sabrina Freeman's well-respected book, "Science for Sale in the Autism Wars", she has a section called "The Classic Aversives Ruse", wherein she takes on "the spurious issue of aversives". Dr Freeman is one of Canada's most important autism advocates. She runs Canada's major FEAT group and was one of the parent petitioners in the Auton case.

Her major point is that aversives are no longer used. They're a relic of the past. This point is frequently made by autism advocates. It was made in the Supreme Court of Canada Auton hearing in 2004, by the Auton parents' lawyer. ABA parents don't want to have anything to do with aversives, which are now ancient history. Everyone knows ABA programs are all positive these days. So aversives are an irrelevant non-issue, and anyone saying otherwise is grossly misguided (at least).

This position is partly right. For a while now, aversives have no longer been part of routine ABA-based autism interventions.

On the other hand, the one published study invariably used by autism advocates to argue for the effectiveness of ABA programs is Lovaas (1987). According to this study's author and its design, its famous result, those 9 of 19 indistinguishable kids, is dependent on the use of contingent aversives.

Autism advocates have also used the Auton trial decision, the US Surgeon's General's report, and the New York State Department of Health guidelines as proof that ABA-based interventions are effective and/or "medically necessary". All three of these favourite lobbying tools are heavily dependent on Lovaas (1987) and its follow-up (McEachin et al., 1993).

Autism advocates also contend that there are multiple replications of Lovaas (1987). There's no evidence to support this claim, not among the very few existing autism-ABA controlled trials, but let's say they're actually right about this. Then they continue to highlight and promote an aversive-based study when alternative, non-aversive studies are available.

This seems like odd behaviour for ABA advocates whose position is that aversives are an irrelevant relic of bygone days.

There are other reasons for not forgetting about aversives, which is in any case difficult to do when Dr Lovaas' famous 47% continues to be a staple of ABA parent lobbying efforts.

One is that aversives continue to be promoted as a necessary part of ABA programs for some autistics in some circumstances. I'm pretty sure Canada's autism advocates would strongly oppose the practices of the Judge Rotenberg Centre, where extreme aversives are used, and the JRC is not generally respected or promoted among behaviour analysts. No one should forget about the "students" at the JRC and what they have to endure. But nor should it be overlooked that some very respected behaviour analysts continue to promote the necessity of aversives in some cases. For example, Richard Foxx recently authored a book chapter about the "myth" of non-aversive treatment for "severe" behaviour (aggression, self-injury; Foxx, 2005). Dr Foxx is one of the best known and most respected behaviour analysts in the world. He was also recently an expert witness in support of ABA parents in a British Columbia legal case. James Mulick, another highly respected behaviour analyst known for his work in autism, recently was an author of a published study using electric shock to treat self-injury. Dr Mulick was an expert witness for the ABA parents in Auton. While those in charge of the JRC may be pariahs in the behaviour analytic and autism advocacy communities, Drs Foxx and Mulick are definitely not.

Another reason not to dismiss any mention of aversives as a "ruse" is that we should learn from the past and from the suffering of others. We shouldn't forget how utterly wrong all those important behaviour analysts--Lovaas, Carr, Risley, Baer, Schreibman, Koegel, etc.--were when they were claiming that without aversives, autistics were doomed. We should all remember that Lichstein and Schreibman (1976), in a review of multiple behaviour analytic interventions using electric shock on autistic children, stated that the main side effect of using electric shock was "positive emotional behavior". They were saying that electric shock made autistics happy, a claim it is hard to imagine being made about typical children. Serious errors in judgment, extreme lapses in ethics, grossly inaccurate observations, etc., have been made and reported throughout the history of behaviour analytic intervention research and this has hurt autistics. We should all remember that.


References:

Auton et al. v. AGBC, 2000 BCSC 1142 (CanLII)

Foxx, R.M. (2005). The National Institutes of Health Consensus Development Conference on the Treatment of Destructive Behaviors: A study in professional politics. In J.W. Jacobson, R.M. Foxx & J.A. Mulick, Eds., Controversial Therapies for Developmental Disabilities. Mahwah, NJ: Lawrence Erlbaum Associates.

Foxx, R.M. (2005). Severe aggressive and self-destructive behavior: The myth of non-aversive treatment of severe behavior. In J.W. Jacobson, R.M. Foxx & J.A. Mulick, Eds., Controversial Therapies for Developmental Disabilities. Mahwah, NJ: Lawrence Erlbaum Associates.

Hewko v. B.C., 2006 BCSC 1638

Lichstein, K.L. & Schreibman, L. (1976). Employing electric shock with autistic children: A review of the side effects. Journal of Autism and Childhood Schizophrenia, 6, 163-173.

Lovaas, O.I. (1987). Behavioral treatment and normal educational and intellectual functioning in young autistic children. Journal of Consulting and Clinical Psychology, 55, 3-9.

McEachin, J.J., Smith, T., and Lovaas, O.I. (1993). Long-term outcome for children with autism who received early intensive behavioral treatment. American Journal on Mental Retardation, 97, 359-72.

Salvy, S. J., Mulick, J. A., Butter, E., Kahng, R., & Linscheid, T. R. (2004). Contingent electric shock (SIBIS) and a conditioned punisher eliminate severe head banging in a preschool child. Behavioral Interventions, 19, 1-14.

16 comments:

mcewen said...

Whilst I denigrate the use of aversives, if one follows an ABA program maybe we are all guilty of 'abuse.' When the children themselves are so phobic of so many things, if we 'force' them to tackle their fears then surely it is all a question of degree? If I were phobic of spiders, then my fear and sensitivity towards them would be greater than someone else's. If you force me to face my fear against my will.....

Joseph said...

And who knows if the Lovaas (1987) results were really contingent on aversives. Maybe the kids were beaten into submission so they act in a way "indistinguishable to peers". But it's impossible to say that for sure when the study wasn't even randomized and the evaluators were not blind to treatment. Never mind a double-blind design, which would be difficult to do in such a setting, admitedly. The Lovaas sampling was clearly skewed, with a near-1:1 ratio of boys to girls.

Michelle Dawson said...

Hi Joseph, I'll be writing a bit more in the next part about the extent to which aversives played a role in Lovaas (1987).

Boyd (1998) raises the problem of male/female ratios in Lovaas (1987). There were 3 girls in the experimental group, and 8 in Control Group 1, out of 19 in both cases (there were 5 out of 21 in Control Group 2). Boyd (1998) points out that the male/female ratios in both the experimental group (too few girls) and Control Group 1 (too many girls) are outside of the range expected for autism.

Boyd (1998) is also the one who revealed that one of the Control Group 1 girls had Rett syndrome.

Anonymous said...

Forcing someone to face their fears against their will is only questionably effective. You may be able to force someone into submission, but not empower them to deal with this. In OCD for example - the patient really needs to understand the purpose of the exposure therapy and be WILLING to participate in it. Otherwise they will often set up barriers so that they appear to develop a limited tolerance (instead of a true tolerance) and can turn to other behaviors to cope.

Jannalou said...

I can say, with authority, that aversives are definitely still used in ABA programs. They're just not called aversives.

All correction procedures can be considered aversive.

Any time you use an overcorrection procedure, that is an aversive.

And these are not isolated incidents; I was required to use overcorrection procedures with more than one child, under the guidance of more than one consultant. One from WEAP (a very highly regarded agency) and one who had done her training in New Jersey.

Kristina Chew said...

The JRC director studied under Skinner, as he makes clear on his website.

The history of behaviorism is indeed not pretty (understatement).

Are low grades (as in D's or F's given to a student) aversive.....

Michelle Dawson said...

Dr Foxx, who I mentioned, is credited with pioneering overcorrection (Foxx & Azrin, 1973). In this paper, overcorrection was used to extinguish "object-mouthing, hand-mouthing, head-weaving and hand clapping."

WEAP is the Wisconsin Early Autism Project, which is Glen Sallow's large international ABA service-providing corporation (in 2004, they had 800 or so employees).

Many events can be aversive (e.g., homework, deadlines, etc., can be aversive to some people), but I was referring to systematically hurting children and adults in behaviour programs, as was Dr Freeman.

Interverbal said...

"All correction procedures can be considered aversive."

I agree with Jannalou here, but I feel the need to specify that "aversive" by itself should be equated with [smacking a kid]. And the corrections are not intentionally aversive (or had better not be!)

Remember an alarm clock going off is aversive. Typing a wrong word can be aversive. Researching something and seeing thatwhat you had thought was wrong, can be aversive.

Michelle Dawson said...

Dr Freeman, and Dr Lovaas in his 1987 paper and elsewhere, are using the term "aversives" in a context where it clearly means deliberately and systematically hurting (e.g., hitting) people in behaviour interventions. The terms "aversive" and "aversives" are not usually context-free when used in the behaviour analytic literature (including, e.g., the two book chapters by Dr Foxx that I reference).

jonathan said...

actually there may have been two girls with Rett syndrome in lovaas' control group and not just one. In his study showing the inefficacy of treating Rett's with ABA there are three girls. One of them is treated at a replication site in Norway, the other two (at least one of whom we know was in the control group) were both described as being part of the lovaas young autism project and both received 10 hours a week of ABA, the same amount given to all of the controls in Lovaas 1987. Wonder if this was a coincidence and wonder why only one of the two girls would end up as a control in lovaas 1987 and not the other. But I guess we will never know the truth.

Michelle Dawson said...

Hi Jonathan, I agree with you that this remains mysterious, and I would sure like to know exactly what happened.

Interverbal said...

"The terms "aversive" and "aversives" are not usually context-free when used in the behaviour analytic literature"

Agreed, and in the same way that reinforcement is not context-free. These terms almost always have context (especially in the research).

Jannalou said...

Overcorrection procedures (which are what I usually think of when I'm thinking about aversives in ABA programs, which I try not to do too often) are supposed to be aversive.

One child, we made him wash his underwear in cold running water whenever he didn't use the toilet for a BM or to urinate. (He didn't have to put on wet ones, just wash them out.) And we had to "help" him do it.

The other child wasn't turning around when doing an imitation drill, so when he didn't "do this", we overcorrected him by re-issuing the command (and doing the action), and then physically standing him on his feet and spinning him around three or four times, then sitting him back down and issuing the command again. Three times, probably, before moving on.

Those are aversives. They are designed to be aversive. And they were in modern ABA programs. The first child I mentioned was in the WEAP-run program; the other was in a program in Vancouver, run by a consultant who Dr Freeman herself knows and recommends.

Michelle Dawson said...

Hi Jannalou, thanks for that information--poor kids. I never know what to do when I run in to anecdotes about problems with well-respected ABA service providers (or in ABA research projects). I'm mostly stuck with what's reported in the science, unless I can find more evidence.

I've participated in a discussion among a lot of people who work with autistic kids, about the problem of discrepancies between what is published in the literature about ABA programs, and what can be actually observed in the practice. Everyone was in agreement that these discrepancies are common (common enough that everyone had observed them). Nobody knew what to do about this.

This is a line from an NYT article (by Daniel Goleman) published in early 1987, circa when Lovaas (1987) was first published:

"We give the kids an occasional smack on the butt if they get too far out of hand," Lovaas said."

Misquote? Did he really mean "thigh"? Did he momentarily mix up the Young Autism Project and the Feminine Boy Project? Who knows.

Chris said...

You're kidding me! Freeman's book is well respected? By whom? I actually bought a copy - I have a completeness fetish - and it seems barely a cut above photocopying and stapling. Owing to a quirk in her word processing one word (or more) had been removed every time it appeared, which tended to make much of the text into gibberish; I was not bright enough to work out what the word was from context and wrote to her, but she couldn't help.

Michelle Dawson said...

Hi Chris, Dr Freeman's "Science for Sale in the Autism Wars" is well-respected (and promoted) by the important leaders of the Canadian "autism community". It therefore represents the standards this community believes autistics deserve.