The Evolution of Autism – Part IV: Treatment

While Bruno Bettleheim was promoting his use of the ‘refrigerator mother’ theory, Dr. Ivar Lovaas was introducing behavior modification to institutions for adults engaging in severe forms of self-injury. In the mid-1960s, he changed demographics and attempted to help children avoid the path of institutionalization by constructing an intervention with the purpose of teaching language to children with autism (in hopes that language would generalize to other core autism deficits like play and self-help skills).

Like Dr. Rimland, he challenged the ‘refrigerator theory’ as well, by portraying children as monsters while promoting mothers as saints for putting up with them.

On 5/7/1965, the photo essay ‘Screams, Slaps and Love’ appeared in Life Magazine, portraying the lives of four children on the autism spectrum. The article focused on the treatment Dr. Lovaas was developing, which used rewards and punishment to change children’s behavior – marking the first mention of Applied Behavior Analysis (the current treatment for autism) in pop culture. Mimicking speech led to food and hugs while displaying unwanted behaviors was met with scolding, shaking, slaps on the thigh; and in rare cases, administration of electric shock. The rapid reduction of even the most horrific behaviors, such as children punching themselves in the face, chewing off their fingertips, headbanging and poking their eyes, helped prove that children with autism were sensitive to consequences. This sensitivity is what made Applied Behavioral Analysis (ABA) so effective; but it also made the autism community question whether the use of aversive interventions, such as electric shock, were necessary.

Many parents came to the treatment’s defense as it showed that children did not have to be confined to a hospital and that there was hope, ignited by the article ended with its most dramatic image: a mother smiling, watching her child hug another child for the first time. After its publication, parents wrote to Dr. Lovaas and Dr. Rimland, pleading for more services and effective interventions for their children with autism. As a result, Dr. Rimland met with Dr. Lovaas and observed his work. After Dr. Rimland successfully tried the therapy on his own son, he and Dr. Lovaas formed the Autism Society of America, to provide information for parents so they could learn more about this new intervention. 

By the late 1980s, Dr. Lovaas felt that the issues regarding punishment was moot as the non-aversive interventions had become so sophisticated and successful, that the aversive punishments were no longer needed. Accordingly, he stopped using them but controversy regarding his use of punishment for nearly twenty years still stained his legacy. Lawsuits emerged sourcing the aversive therapy as an abuse of power by mental health professionals that can cause lasting emotional trauma. In 1993, Dr. Lovaas published Long-Term Outcome for Children with Autism Who Received Early Intensive Behavioral Treatment, the ‘1993’ Study, following up on the children from the 1965 article. The findings showed that 90% of the children maintained their gains and were productive members of society – showing that even with the negative side of the treatment, there was no debate that Dr. Lovaas had successfully created an intervention that consistently worked on individuals with autism. 

Today’s ABA revolves solely around positive and negative reinforcement and positive and negative punishment, completely eliminating the use of aversive treatment.

• Positive reinforcement works by presenting a motivating stimulus to the individual after the desired behavior is exhibited, making the behavior more likely to happen in the future – such as administering hugs for mimicking speech.

• Negative reinforcement works by removing an aversive stimulus to enhance a behavior. An example would be: before heading out for a day at the beach, you put on sunscreen (the behavior) to avoid getting sunburned (removal of the aversive stimulus). By eliminating the undesirable outcome, i.e. sunburn, the preventative behaviors become more likely to occur again in the future.

• Positive punishment works by presenting an unpleasant consequence after an undesired behavior is exhibited. Examples include adding chores and responsibilities when a child fails to follow the rules or assigning students who forget to turn in their homework to additional work.

• Negative punishment works by removing a reinforcing stimulus after an undesired behavior is exhibited. Examples can include a child kicking a peer and being removed from their favorite activity or a teenage girl getting grounded after staying out for an hour past her curfew.

ABA can be thought of as applying behavioral principles to behavioral goals and carefully measuring the results. It helps children with autism to use “expected” behaviors and control some of their more challenging impulses. ABA can be administered 1:1 in a classroom, or in natural settings such as playgrounds, cafeterias and community locations. As individuals begin to master behaviors, they are able to generalize the behaviors they learn and incorporate them into ordinary social experiences; making a huge difference in how well they manage school and social experiences.

Additionally, ABA has been used to help individuals acquire many different skills, such as language skills, self-help skills and play skills; effectively improving quality of life for individuals living on the spectrum.

Sources:

• (Photo Credit) Dr.Ivar Lovaas. KultureCity
• Rudy, Lisa. What is ABA (Applied Behavioral Analysis) Therapy for Autism? verywellhealth. 2018.
• Bowman, Phd, Rachel and Baker, MD, Jeffrey. Screams, Slaps, and Love: The Strange Birth of Applied Behavior Analysis. American Academy of Pediatrics. 2013.
• Grant, Allan. Screams, Slaps and Love – photo essay. 1965
• Smith, Tristram and Eikesth, Svein. O. Ivar Lovaas: Pioneer of Applied Behavior Analysis and Intervention for Children with Autism. Journal of Autism and Developmental Disorders. 2011.