Tuesday, 29 October 2013

BBC4 “Challenging behavior” film on ABA and autism - Guardian article

In today’s Guardian newspaper, Chloe Lambert asks “It is right to try to ‘normalise’ autism?” in an article prompted by the upcoming BBC4 documentary film “Challenging Behaviour” (awful title, I hope the film is better). The article can be found at:

So, we have an article with that interesting question but the story is all about the use of ABA as an educational approach for working with children with autism. The question is important, and it is an ethical one. To use this question as a title for a piece about ABA-based autism education is unhelpful mostly because I argue that ABA is nothing to do with ‘normalising’ autism just as ABA isn’t an intervention for autism of course.

I’ve written extensively, and in the public domain on this blog, to help people get a better understanding of the use of ABA methods as an educational approach for children with autism. To be fair, the Guardian article does (I think) a pretty good job of giving a picture of how ABA is used flexibly to work on a number of key areas for children, is individualized, reward-focused, and has pretty good outcomes. The aspect that makes my heart sink is to see quotes from autism experts that, again in my view, just aren’t accurate.

Please take a look at my description of ABA and its use with children with autism. This does relate well to the Guardian article, but is in a little more depth:

It is a real shame to see the ‘normalising’ issue coming up yet again, especially in the quote from Liz Pellicano (who I think is fantastic, btw) suggesting that the “underlying ideology of ABA” is “to make them indistinguishable from their peers". This is a criticism of ABA about which I have a very clear view. Here’s a full quote from my earlier blog on criticisms of ABA (see the full blog at http://profhastings.blogspot.co.uk/2013/03/autism-and-evidence-5-15-criticisms-of.html ):

The criticisms here focus on a number of related points. The first is that ABA approaches are focused on taking away something of the child’s autism – trying to make the child “normal” in some way. Critics argue that this also leads to proponents of ABA approaches trying to convince parents and others that they can “cure” a child of autism, or more generally that “ABA can lead to recovery” from autism. A second area of criticism is that ABA focuses on reducing/removing behaviours that cause no harm for the child and in fact are functional for them (especially stimulatory behaviours – “stims”).

Some discussion of this issue can be found in two of my previous blogs, so please take a look at those first:

In summary, ABA approaches in autism do not “decide” which behaviours to focus on in terms of developing new skills or reducing existing problematic behaviours. Multiple perspectives are used to identify targets for intervention including the child, their family, teachers etc. Ethically speaking, behaviours ought to be the target for reduction only when suitable alternatives are available for children (and these may have to be taught), and when the behaviour in question is clearly interfering with an aspect of the child or family’s experience of quality of life. Sometimes, “stims” may be targeted for reduction for these reasons, but there is no prescription to do so as a part of an ABA programme.

When it comes to a broader normalizing agenda, this is an issue that is not specific to ABA. In fact, educationally focused interventions in general ought to be about making a positive difference and not succumbing to a medical model agenda of cure or recovery.

That said, unfortunately, it is true that some proponents of ABA sell their services on the basis that recovery “is possible”. Thus, many people may have heard these qualified promises, or perhaps stronger promises made. However, proponents of many other interventions in autism also make similar (sometimes much stronger) claims. The fact is that many interventions exist within a marketplace where they are trying to attract attention of parents as “consumers”. Until autism organizations and government bodies recommend (and fund) only interventions with a clearly demonstrated evidence base, this marketplace will continue to function.

An important point to make is that just because some individuals or organizations argue that ABA can lead to some sort of recovery from autism does not mean that this is what ABA is all about.

It is also important to point out that the same autism experts who criticize the potential ‘normalising’ focus for ABA suggest that autism symptoms ought to be the outcomes measured in autism intervention research. This is a rather odd positioning, and not one that is core to the ideology of ABA at all. The whole field is tainted by a medical model of autism (see http://profhastings.blogspot.co.uk/2013/04/autism-and-evidence-6.html ).

A further autism expert view from the Guardian article is the following: “Dr Luke Beardon, senior lecturer in autism as(t) Sheffield Hallam University, argues that ABA's focus on behaviour and rewards means that children may not learn how to make decisions for themselves”.

I’m not sure how children are meant to learn how to make decisions if it is not taught to them, and they learn the outcomes of making decisions. Again, this robotic learning undertone (also mentioned elsewhere in the article) is spouted by people who just don’t know what they are talking about! Again, my blog opening discussing criticisms of ABA has lots of “answers” on this issue and related ones - http://profhastings.blogspot.co.uk/2013/03/autism-and-evidence-5-15-criticisms-of.html

In concluding the article, a question is asked why ABA isn’t used more in UK schools. One answer, once you understand what ABA is, is that ABA is used everywhere and underpins much of modern evidence-based education. So, it is a strange question. Specifically in relation to autism though, the conclusion is: “Much of the evidence suggests that autistic children do best with a combination of approaches.” I’m afraid this is total rubbish, and it is hard to be patient at all with such a statement. I do not know of Randomised Controlled Trials comparing an approach to autism education that is eclectic in its use of approaches, versus a clear model like a behavioural education model, against typical education for children with autism. Educational delivery models are rarely tested in autism at all, so the evidence to support such a conclusion is missing. Interestingly, there are UK data (not from a RCT – please do note) showing better outcomes from a behavioural education model compared to eclectic education as usual for children with autism (see http://profhastings.blogspot.co.uk/2013_06_01_archive.html )

So, Chloe Lambert at the Guardian, a good attempt to provide an interesting and balanced perspective on ABA and autism. When will someone truly update for the public what ABA is and how it might be used to improve education for all children, including children with autism? I know it can be hard to find the “moderates” who are supportive of ABA, but we are out there…

Fingers crossed that the BBC4 film itself gets this right. Tuesday 5 November at 9pm (http://www.bbc.co.uk/programmes/b03gvnvm ). The description on the BBC4 website suggests that the focus is yet again on the ‘normalising’ debate. Let’s see if it makes good TV, and more importantly if it is smart and balanced.

Wednesday, 23 October 2013

The challenge for behaviour analysis in the UK: Some thoughts on the future

If you have read some of my other blogs, you could be forgiven for thinking that my interest in the application of behavioural interventions is dominated by their use in the field of autism. Quite the contrary. The autism and behavioural interventions community is an important part of behavior analysis in the UK, but it is clearly not the full story.

We are at an interesting point in the development of behavior analysis in the UK. The UK Society for Behaviour Analysis [http://uk-sba.org/] has been established recently and held its first Annual General Meeting a couple of weeks ago. There is also an increasing recognition of the value of interventions in a variety of areas that are based on core behavioural principles. Just focusing on the health and social care domain, the UK National Institute for Health and Care Excellence (NICE) has recommended a range of behavioural interventions and approaches within its guidelines including:

  • Behavioural activation for depression
  • Dialectical Behaviour Therapy for personality disorder and self-harm
  • Behavioural parent training to support families of children with behavior problems
  • Behavioural intervention, including functional assessment, for challenging behaviours in people with dementia, adults with autism, and children with autism
  • Behavioural skills teaching methods for adults with autism

NICE is also currently working on a guideline that will recommend interventions for challenging behaviours in adults with intellectual disability. Given that national guidance in the UK already identifies Positive Behavioural Support (PBS) as the intervention model of choice, it seems likely that PBS will emerge as a strong part of the future NICE guideline.

That short overview is health/social care focused, but behavioural interventions are the bed-rock of evidence-based approaches in a range of other situations including teaching in schools, behaviour management in schools, “nudges” to change behaviour on a large scale across the population, safety in high risk industries, and “incentivizing” performance in many business contexts.

If we take a broad perspective about behavioural interventions, it seems that the momentum is with the application of behaviour analysis in the UK. Several behavioural interventions are already recommended for use. This should be a fantastic time. The opportunity is significant because the needs are significant. If we imagine the often-used picture of an iceberg, behavioural interventions are only addressing a tiny fraction of the children and adults in the UK who could benefit. As an example, we carried out a census of schools and school units in the UK who follow explicitly a behavioural educational model across the whole of the curriculum [http://www.sciencedirect.com/science/article/pii/S1750946711001875]. These schools catered for a total of 258 children with autism. This does not compare favourably to the total population of school aged children with autism in the UK.

So, there is a massive amount of work to do to disseminate behavioural interventions more widely. This is the current and future challenge for behaviour analysis in the UK.

How might the behaviour analysis community in the UK meet this challenge? First, we need a body in the UK that explicitly focuses on the dissemination of behavioural interventions across all sectors in society. The existence of the new UK-SBA is a real benefit in this respect. If the UK Society can avoid navel-gazing such as a primary concern with the needs of behaviour analysts rather than the needs of society, there is great hope.

A second issue is that it is important to identify the areas for growth and to run with the opportunities. This might involve re-claiming existing behavioural interventions for behaviour analysis. Thus, we need, for example, to re-claim parent training and behavioural activation for depression. In addition, we need to understand where the energy is for change. Because of the significant interest across the UK in the Winterbourne View scandal [see http://profhastings.blogspot.co.uk/2013/05/winterbourne-view-will-happen-again-and.html], there is great energy for PBS at the moment.

Third, those with strong behavioural competencies and allegiance to behaviour analysis need to be out there in the debates about evidence based intervention in a variety of contexts. It is amazing when you look how many evidence based interventions are built on basic behavioural principles. It is not necessary to rub others’ noses in it so to speak, but we need skilled communicators who can keep the connection with behavioural theory and practice as much as possible. Essentially, we need influencers who are the friendly face of behaviour analysis and can use their influence to support the dissemination challenge.

A final point is that actually behaviour analysts/behavioural psychologists need to explicitly study/research why there is such a large gap between the needs behavioural interventions can address and actual roll-out in society. We need behavioural analyses and interventions to deal with this problem directly. For example, anecdotally, the language used by behaviour analysts is off-putting and confusing. So, we need to understand the barriers to the uptake of behavioural interventions and then we can remove them.