The following article is from The Communicator (Fall 1995) Newsletter of the Autism National Committee

LOVAAS THROWS "CAUTION" TO THE WINDS And rebuts AUTCOM'S cautionary memorandum by declaring behavior mod the only proven treatment; states that speech and language therapy, sensory and motor integration therapy, and special education "have failed to show effectiveness"

In April of this year, the Autism National Committee approved for distribution a cautionary memorandum on the exclusive use of discrete trial training for children diagnosed with autism/PDD. This 2-1/2 page document was prepared in response to a steadily increasing volume of inquiries about the justifiability of extremely intensive, rigorous and repetitive behavioral conditioning of these young children, the goal being their acquisition of discrete cognitive and language skills which can be produced via "prompts."

A number of factors could be seen to play into the latest resurgence of interest in this regimen, among them the recent legislative mandates which opened new funding streams for early intervention services, an increasingly strident and incautious rhetoric suggesting that children could be "recovered" or "cured" of autism via intensive early conditioning, and the publication and promotion of the 1993 volume, "Let Me Hear Your Voice," by a mainstream publisher. This autobiographical account by the pseudonymous Catherine Maurice, who refers to autism as a "psychosis," and to a child with autism as "a person without a self" and "a life without a soul," argues for a child-rearing philosophy based on "obedience" and "behavior." Maurice vows that her daughter with autism "will be dragged, kicking and screaming, into the human condition." As her therapeutic model, Maurice cites the work of Professor Ivar Lovaas of the UCLA Clinic for the Behavioral Treatment of Children, who wrote an enthusiastic "Afterward" for her book.

Ivar Lovaas has now contacted the Autism National Committee with the 10-page text of a rebuttal to the cautionary memo which we have been distributing upon request, informing us that this rebuttal will be published in the semi-annual newsletter of his Clinic.

The Committee's objections to this upcoming publication by the Clinic for the Behavioral Treatment of Children are fourfold: misquotes and quotes taken out of context from our original memo; a disingenuous attempt to pit parents against parents by suggesting that our consumer memo "may play a role in denying your child funding for such services"; rash assertions which may actually lead to the devaluation and denial of such basic services as special education; and an alarmingly narrow representation of the field of autism which leaves readers with no indication of the wealth and diversity of current research and treatment approaches.

Where the Committee's memo focused on the "discrete trial training" skill-by-drill approach which has come to make up an inordinate, often total, part of the early intervention for some youngsters with autism, the Lovaas rebuttal substitutes the words "one-to-one in-home treatment" and 'behaviorism." No one here denies the value of working with one's child one-on-one, in the home. What parent doesn't?

"Behaviorism," on the other hand, is hardly our chosen subject for a 2-1/2 page memo, necessitating as it does a consideration of the history of Western philosophy and science. If the stakes are to be widened to a more thorough discussion of behaviorism, however, these words of Noam Chomsky, who long ago proved behavioral interpretations of language development to be wholly inadequate, embody an argument against behaviorist assumptions which is hardly new, and upon which we would not presume to improve: "We tend too easily to assume that explanations must be transparent and close to the surface. The greatest defect of classical philosophy of mind...seems to me to be its unquestioned assumption that the properties and content of the mind are accessible to introspection...A similar defect mars the study of language and mind in the modern period. It seems to me that the essential weakness in the structuralist and behaviorist approaches to these topics is the faith in the shallowness of explanations, the belief that the mind must be simpler in its structure than any known physical organ and that the most primitive of assumptions must be adequate to explain whatever phenomena can be observed. (Noam Chomsky, Languge and Mind, 1968, pp. 25-26).

In this vein, the Committee's memo reminds parents that behaviors targeted for suppression/extinction "simply because they are deemed 'cosmetically' undesirable" may likewise benefit from less simplistic assumptions and from explanations which are fully explored: we advise that these behaviors may "indicate the nature of the child's sensorimotor disturbances...may be involuntary, may be a calming device, may be the necessary adjunct to call forth some other movement, and so forth."

After widening the terms of our original memorandum to include "behaviorism" in general, the Lovaas rebuttal goes o to selectively and misleadingly quote from the document itself. For example, our memo suggests that young children need the opportunities AND SUPPORT to participate in the natural life of the family and community, to have friends and relationships" (emphasis added) rather than to spend 30 hours a week or more in behavioral training sessions, as is the case in many programs we have observed. However, the rebuttal chooses to pretend that we favor "placing the child in a 'natural environment' without helping him develop the skills to interact in that environment" and that we are therefore guilty of "set(ting) the child up" for "failures."

Another technique of this rebuttal is to sidestep or reconfigure the points raised in our memo. For example, Lovaas cites his own data, compiled as an "interim report" as part of a government grant, to refute our observation that intensive behavior-oriented home training programs can be particularly stressful to family life by stating that the parents he studied "do not experience more stress than parents of children with autism who do not participate in such programs." This may well be true, depending on what ELSE your control group is ALSO is not participating in! But we hereby inform the families who have characterized such behavior conditioning programs as disruptive, unhappy experiences that their testimony has been scientifically proven inaccurate.

Many families who have "been there" have also warned us that, as our memo notes, "siblings in particular may come to lack the attention they need, while the focus on a sibling's disability may derail the development of more positive sibling relationships." To this the Lovaas rebuttal offers a NON SEQUITUR, stating "There is no reason to believe that siblings of a child who improves in treatment will fail to develop positive relationships with that child."

In some cases the author(s) of the rebuttal seem to labor under an inadequate reading of the Committee's memo. For example, the Committee cautions that self-stimulatory behaviors may be inappropriately targeted for behavioral extinction by therapists who do not recognize their nature. The Lovaas rebuttal argues: "It is misleading to state that behavior therapists extinguish self-stimulatory movements. There is little or no data to show that self-stimulatory behavior can be extinguished." Our point precisely!

Again, the rebuttal angrily refutes a claim which the Committee has never made: that "Untrained and minimally trained personnl can implement behavioral treatment." Indeed, our memo cautions parents to BEWARE OF the hiring of untrained or minimally trained personel, although in practice this is often done in order to fill the long hours of behavior trials and corrections (for example, we are aware of many families who are attempting to staff in-home programs by placing newspaper ads, hiring high school students, and so forth.

Astoundingly, the Committee is chastised for suggesting a vigilant awareness of the dangers into which this therapy can, and in the past did, fall. Yet it is insufficient for Lovaas to simply declare our concerns about the potential for "the escalation of therapy to aversive levels" to be, in the words of the rebuttal, "incorrect and misleading." Given the premises of this therapy and its past espousal of aversives, we would be remiss in writing a consumer caution which did not raise awareness of the issue, for those who do not remember the past are doomed to repeat it.

Lovaas corrects our statement that "behavior therapy" is often touted as a "cure" for autism, so perhaps it is time to have our hearing aids checked. Or perhaps not, for he then informs us that we have correctly heard the term "recovery" used to describe "the best-outcome subjects." Since our Merriam-Webster Dictionary defines recovery as "to regain normal health, poise, or status," we fail to see the difference. Since Lovaas agrees with us that the typical self-stim behaviors of autism are one variety that cannot be extinguised, it is difficult to imagine what this "recovery" of "normal health, poise" would look like.

The expansive interpretion given to the concept of "recovery" is only surpassed by the expansive interpretations given to a narrow portion of the research literature in this rebuttal. We all know that, for any point anyone ever wishes to make, a sufficiently thorough search of the literature will locate some article, somewhere, which can be cited in support. Thus, for the patently ridiculous claim that "behavioral treatment is the only form of treatment that has been supported by a body of empirical evidence," Lovaas cites a single article published 14 years ago in the Schizophrenia Bulletin. He is able to state that behavioral treatment "has been described as the treatment of choice for autism" thanks to that same article. Indeed, we know of articles in which autism "has been described" as a psychosis, a vitamin deficiency, and a plague unleashed by Martians, but that does not make it so.

Claims are made far out of proportion to anything the literature will bear. To justify the assertion that "Behavioral treatment is supported by a larger range of scientific findings than any other therapy available for children at this time," Lovaas refers again to his own articles concerning his single small, pre-selected study group.

Even where modest but seemingly supportive data exists, however, we must remember that it is not difficult to construct objective tests that are certain to demonstrate the effectiveness of such training methods in reaching certain goals that are incorporated in the tests. However, successes of this sort to not demonstrate the importance of the goal -- that is, they do not demonstrate the ultimate value and significance of concentrating on training the child in discrete behavior and language skills as oposed, for example, to more naturalistic methods of communication and relationship-building based on models of the stages of normal child development and an awareness that children with delays and disorders must be purposefully guided through those stages. Feasibility and significance remain two separate questions.

Yet the love of data is a strong love, regardless of significance. To our contention that discrete trial training and related behavioral techniques are hardly news, Lovaas contends that "one-to-one behavioral therapy is continuously evolving and new data-based programs are added at a rapid rate." Perhaps they are. But, to borrow another quote from Chomsky's prophetic analysis, "...to a considerable degree, I feel, the 'behavioral sciences' are merely mimicking the surface features of the natural sciences; much of their scientific character has been achieved by a restriction of the subject matter and a concentration on rather peripheral issues. Such narrowing of focus can be justified if it leads to achievements of real intellectual significance, but in this case, I think it would be very difficult to show that the narrowing of scope has led to deep and significant results." (Language and Mind, p. ix) No mere tally of "new data-based programs" will answer the question of the significance of their results.

The Autism National Committee closes its consumer memo by recommending a wide range of therapies and supports which have proven valuable: "We need to take advantage of improvements in speech and language therapy, in the application of assistive devices, and in the use of sensorimotor integration therapy to address the sensory processing challenges which, by their very nature and complexity, are entirely beyond the range of behaviors on which discrete trial training might have an effect."

Given the Committee's obvious commitment to seeing this wide range of positive approaches utilized, it is disingenuous to suggest that we are out to see funding denied to children and to "build walls between professional persons." However, the conclusion of the Lovaas rebuttal is chilling, and likely to have both of those effects. He writes that, "Speech and language therapy, sensory and motor integration therapy, special education, and other therapies have failed to show effectiveness." The "proof" cited for this extraordinary assertion is the 1993 Handbook of Effective Psychotherapy, ed by T.R. Giles, which contains a segment on autism by "T. Smith," presumably the same T. Smith who coauthored with Lovaas three of the articles in the References to this rebuttal. In the "Handbook," Tristam Smith of UCLA thanks Lovaas for helping him prepare this contribution.

At a time when the Autism National Committee is fighting hard for a complete reauthorization of the federal right-to-education legislation, when we are just beginning to make our schools understand the implications of autism as a disorder of speech, language, and sensorimotor integration, this devastating and insupportable conclusion truly takes us back to square one...where, lo and behold, behavioral training would be all that is left.

Of the twelve entries cited in the references to the Lovaas rebuttal, seven list Lovaas as sole or joint author. Only three -- two co-authored by Lovaas as well as the "autism" entry by T. Smith, cited above, in the Handbook of Effective Psychotherapy -- have a publication date in the 1990's. To bring you up-to-date on the many other researchers, educators, and successful appproaches to the treatment and teaching of children with autism, the Autism National Committee offers this recommended list (with the caveat that it is far too short to be definitive):

For parents of very young children: Trans-disciplinary Play-Based Intervention, by Toni Linder, University of Colorado. Contains good descriptions of child development and intervention strategies in the area of cognitive, social-emotional, communication and sensorimotor development.

Kindergarten through young adulthood: The Syracuse Community Referenced Curriculum Guide, Alison Ford, Ph.D., and colleagues,Syracuse University. Terrific resource, includes suggestions for IEP goals in all skill areas. ALSO Choosing Options and Accommodations for Children (COACH), Michael Giangreco and colleagues. A guide for planning inclusive education programs. Clear options, excellent resource for IEP development.

Children of all ages: Teaching Children with Autism: Strategies to Enhance Communication and Socialization, edited by Kathleen Ann Quill

Help in advocating effectively for school services: You, Your Child, and Special Education, by Barbara Coyne Cutler. Wonderful, common-sense approach to parent advocacy. Good examples of real life situations.

All ages: Movement Differences and Diversity in Autism/Mental Retardation, by Anne M. Donnellan, Ph.D. and Martha Leary, MA, CCC-SLP. Contact DRI Press, P.O. Box 5202, Madison, WI 53705, Phone and Fax 608-739-3747

Many, many good resources are available from Brookes Publishing, PO Box 10624, Baltimore, MD 21285-0624, Phone 1-800-638-3775. Ask for the excellent catalog!

A few more recommended authors to look for: Judy Duchan, PhD; Glen Dunlap, PhD; Stanley Greenspan, MD; Barry Prizant, PhD; Ann Turnball, EdD, and Rud Turnbull, PhD (The Beach Center) and the many works of all the fine contributors to the volume Teaching Children with Autism (cited above).