All day I think about it, then at night I say it. Where did I come from, and what am I supposed to be doing? I have no idea. My soul is from elsewhere, I'm sure of that. And I intend to end up there...Who looks out with my eyes? What is the soul? I cannot stop asking. If I could taste one sip of an answer, I could break out of this prison...I didn't come here of my own accord, and I can't leave that way. Whoever brought me here will have to take me home.

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21 January 2010

World Autism Interviews: Alex Cheezem/Applied Behavior Analysis

Alex Cheezem is autistic. He recently completed Nova Southeastern University's program in Applied Behavior Analysis and is presently engaging in supervised fieldwork, with approximately 250 hours remaining before he can sit the BCaBA exam. Alex's hobbies include reading Cochrane Reviews, trolling epidemiology journals for experimental methodology articles, and following autism research.

E: Please share a summary of your background, experience, knowledge, and training in relation to ABA.

Alex: I suppose my background and experience start when in my adolescence. While I was running the metaphorical gauntlet of misdiagnoses that many of us on the spectrum seem to experience, one of the "treatments" I was subjected to -- based on a complete misunderstanding of what was going on with me -- was a particularly incompetent form of ABA-based "therapy".

I have to clarify on this that I don't just mean that the people in question were abusive. They were using abuse as a substitute for skill and understanding, and their lack of those was pretty extreme.

That experience left me rather thoroughly traumatized, but I eventually got a sense of closure and moved on.

I studied ABA as part of my undergraduate psychology courses, and entered the postgraduate BCBA/BCaBA certification program at Nova Southeastern University in August of 2008. I completed the full BCBA coursework as of August of 2009. At present, I'm about 250 hours of supervised independent fieldwork away from taking the BCaBA exam -- the BCBA exam will have to wait until I get a Master's.

I've completed two semesters of practicum in ABA at the Mailman Segal Institute for Early Childhood Studies. Most of that time was spent working with the Baudhuin Preschool, which specializes in autistic children. I'm presently working on setting up supervised fieldwork, but running into a variety of delays.

E: Is the ABA approach for children who are on the spectrum regulated by a professional organization?

Alex: That's a misleading question -- there isn't a singular ABA approach for anything, much less for autistic children. That said, such approaches are supposed to be. I phrase it like that because the Behavior Analyst Certification Board really only has control over people who certify as behavior analysts, and not everyone who practices based on ABA does for a variety of reasons.

This can be benign -- for instance, psychologists often incorporate behavioral techniques into their practice; in that case, their practice simply falls under different authorities (and, frankly, stricter ethical codes). It can also be quite problematic.

The full situation is phenomenally complex, and doesn't lend itself to a brief answer.

E: What do you feel are the positive aspects and benefits of using an ABA approach with children who are on the autistic spectrum?

Alex: I think I'll need to take a step back and address what ABA and ABA-based approaches are. Modern ABA really started as a reaction to psychoanalytic theory, and its roots really show in a lot of places.

In essence, B.F. Skinner decided that the explanations based on inner processes and subconscious hypotheticals were responsible for a lot of the problems with psychoanalysis, and decided to go in the opposite direction. Contrary to a number of people's beliefs, he didn't say that those processes don't exist, but rather that they couldn't be directly observed and thus would be difficult -- if not impossible -- to study.

Anyway, several of the advantages of behavioral approaches to dealing with issues come from the fact that ABA basically ignores the mind and inner experiences and instead focuses on observable, measurable behavior.

How a behavior analyst practices -- or is supposed to practice, anyway -- is by measuring and observing patterns in behavior. Based on these patterns, they then make changes in that environment (including the behavior of the people in it) in order to exert prospective control over some aspect of people's actions.

There are obvious potential issues here, but discussing them doesn't really lead to an explanation of the advantages to ABA-based approaches.

Despite the best efforts of some truly gifted researchers, we still really haven't come to a practical understanding of autistic learning processes and how they differ from neurotypical learning. Since we don't have that understanding, the best we can really do in clinical practice is to acknowledge this.

What I'm trying to get at here is that ABA-based approaches don't require knowledge and understanding that we don't have. I'm sure that we'll develop better methods in time, but we certainly aren't there yet.

ABA-based methods are also extremely flexible. The same basic approach can be applied to getting a child to stop tantrumming at mealtime and to get him to learn arithmetic.

Finally, I suppose I should mention that the empirical support for ABA-based methods is generally better than that for any other type of autism approach available... although that is admittedly not saying much.

E: Explain the potential dangers, drawbacks, or negatives related to ABA-based therapies for autistic children.

Alex: There isn't exactly a shortage of them.

When you practice based on ABA, you are attempting to manipulate or control what someone else does… and there's a huge number of problems with this, mostly centered around the issue of someone deciding what is acceptable behavior for someone else.

Understanding behavior analysis does not mean understanding autism. Many behavior analysts basically think of autism as nearly interchangeable with mental retardation, certain issues in Angelman's Syndrome, and so on, mentally lumping all of the conditions together as "developmental disabilities". This is not accurate... and the confusion can lead to a number of problems.

Then, of course, there are the people who make inflated claims about just what practice based on ABA can or can't do, those who don't practice based on the evidence, and those who don't seek adequate training and/or understanding. Frauds and incompetents exist in just about any profession, but I think the ABA-based ones are particularly vile.

There's the dangers involving focusing on what a person does rather than on the person themselves. The technical language of behavior analysis doesn't help with this.

There's also the various research issues, like lack of placebo control, lack of blinding, lack of randomization in trials, lack of control for expectancy effects... I could go on and on here, but I tend to laugh inwardly when ABA-based methods are described as "scientifically proven". Beyond the more general fact that science doesn't prove anything (it works by providing evidence, and specifically by providing evidence against ideas, not for them), very few of the studies I've seen are even capable of providing a level of evidence that would be acceptable in, say, Circulation Research.

Of course, they provide a level of evidence that's much higher than most of the education research I've seen, so take that as you will.

E: What do you feel is most misunderstood about ABA in general?

Alex: Everything -- the list starts with just what ABA is and continues straight on from there. It often makes it nearly impossible to get legitimate criticism of ABA and ABA-based practice from people other than behavior analysts... even if the people writing the criticism have legitimate points.

For instance, I ran across a detailed criticism of "ABA" a few months ago that would have been almost entirely correct... if you'd substituted the phrase "Lovaas-type DTT" for every usage of the term "ABA". Suffice it to say that Lovaas-type DTT and ABA are most certainly not the same thing, even if Lovaas-type DTT does have ABA as its theoretical basis.

E: Thank you for your time.

Another blog post on this subject: The Language of Therapy

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