Side Effects of Behavioral Treatments

[Note: in this article, 'behavioral treatments' does not refer solely to the field that BF Skinner and Ivar Lovaas were involved in, but to any treatment in which the 'active ingredient' is some kind of experience rather than a biological agent. For example, psychoanalysis, floortime, music therapy, remedial education and sensory integration therapy are all examples of behavioral treatments.]
A lot of people understand that biological treatments, such as medications, can have unwanted effects. Some people understand that these unwanted effects can be permanent. Therefore, most people don't want to try some biological treatment unless they feel pretty sure it's the best option. (Granted, some people aren't so cautious, but many are.) Most people understand that making the wrong choice regarding a biological treatment can have serious impacts.
But a lot of people don't understand that behavioral treatments, too, can have side effects. They think 'well, it can't hurt, may as well try it'.
This view is encouraged by the people who offer behavioral treatments, because unlike medications, most behavioral treatments have no studies into the potential side effects. Indeed, many behavioral treatments have few or no studies of any effect of the treatment, much less side effects. However, even treatments such as ABA, which have a lot of research into their effectiveness, seldom study side effects. When I searched on PubMed for '"applied behavioral analysis" side effects', the only study I found was "Behavioral epidemiology of food additives" (PubMed ID 299572), which seems irrelevant. (PubMed has a tendency, when it can't find what you searched for, to select something that might have some of your search terms but isn't actually what you're looking for. It's just a quirk of their search engine.)
A big part of the problem is that the people studying a behavioral treatment are often quite blinded by their particular theory. With biological treatments, researchers tend to pick what treatments to try and how to measure effectiveness based on their theory, but side effects seem to be a mismash of theorized potential side effects based on several theories as well as things that are just common side effects of medications and whatever other side effects someone happens to notice. With behavioral treatments, however, many researchers seem to stick so much with their theory that they can't see the side effects, because those side effects don't fit their theory (in theory, the treatment is typically just fine).
In ABA, for example, the few times they happened to mention side effects, these are solely behaviors. Very often they're talking about something they actually wanted (ie generalization) rather than an adverse effect. The few times they discuss adverse effects, these are increases in unwanted behavior, often fairly minor things (eg a child punished for climbing on furniture starts sitting on the back of her chair instead of on the seat) which are felt to be an attempt to find other ways of getting the reward they used to get from the target behavior. The treatment is typically to change contingencies so these side effects are eliminated the way the target behavior was.
In other words, only the side effects that fit their theory are seen, and typically they're interpreted in a way that assumes the treatment is good. This is true in so many contexts. Bruno Bettelheim described children regressing in bowel/bladder control in his school, which he viewed as a sign of progress - a form of self-expression in a child who previously couldn't show those feelings at all. Another common method is to describe the side effects as being a sign of an improperly done treatment, which can get pretty ridiculous when you start claiming (as Ron Leaf did at the conference I attended) that 90% of people using your favorite treatment are doing it wrong, on no evidence other than that the treatment had adverse effects. While people involved in biological treatments often say that using them improperly is a common cause of adverse effects, only the quacks think their treatments can't have adverse effects when used properly. (The problem is that almost all the people involved in behavioral treatments basically think like quacks, even many of those using well-documented treatments.)
Given that it's so hard to find accurate information about adverse effects of behavioral treatments, many people assume these do not exist. But they do. Here are some ways to estimate the risks:

• Look for stuff written by people who oppose that treatment. Studies are best, because then you'll have documentation. But if they don't have studies to back them up, you'll have to go to the studies by the proponents, and 'read between the lines' to see if there's evidence that supports what the opponents say. Focus on the data, not the interpretations of it, to find this evidence. For example, if you find stuff by opponents of ABA saying that extinction of a useful behavior can cause learned helplessness, and then find a study in which a child showed reduction of many different behaviors when one behavior was being extinguished, you've found some evidence in favour of the opponents' theory (not proof, but evidence suggesting that theory).
• Imagine how you'd feel in that situation. If you think you'd have trouble with that, why? If you think you'd be fine, what could change to make you have trouble with it? Imagine it in the context of each theory you find. For example, to assess the risk of adverse effects of faciliatated communication on an autistic person, you'd have to try to imagine yourself both as a person who is truly communicating through FC and as a person who is having words 'put in their mouth' by FC. When assessing the risks for others involved, use the same kind of method - eg how would you feel if you thought your child was communicating with you but it was just the faciliatator, as opposed to how you'd feel if your child really was communicating. Remember, when assessing these, that the different theories aren't necessarily equally probable. Use what evidence you can find to assess the probabilities.
• Lastly, keep watch on the impact it has when you try it. A good marker of the risk of a treatment is how happy or sad the person is when being treated. If they're happy, usually (not always, but usually) the worst that can happen is that the treatment doesn't help. If they're unhappy, that's when the risk of harm is higher.

Creating Panic

I've been meaning to write this since we went to the ARM conference, but I've been putting it off thinking I'd link to our conference presentation with this. Then my mother pointed out that our conference presentation has some stuff about me, such as pictures, that I'd rather not have people viewing over the Internet. So, if I can think of a way to edit it so it doesn't reveal stuff I don't want revealed, I'll look into to putting it up, but in the meantime and in case I don't put it up, here's the post I was thinking of.
I've known for a long time that many parents of autistic kids are desperately worried about curing their children. It's hard to do much in autistic self-advocacy without seeing that. And I knew the 'experts' were reflecting this desperation by peddling miracle cures. I just sort of assumed that parents were so desperate because of societal intolerance for difference, and that the experts were simply responding to that. This is the idea encouraged by a lot of criticisms of quacks 'taking advantage of people's desperation', an idea fairly accurate in the area of cancer treatment that has also been applied to autism treatment.
But my mother's conference presentation argued something different. She looked at the stuff that I found, and suggested that the experts were in fact creating this desperation, not just responding to it. When they say unfounded claims like '90% of untreated autistics are institutionalized' (popularly tossed around by ABA proponents, with no reference ever being given) or 'you can't wait nine months for an assessment, you can't even wait two months' (which was said by Dr Greenspan in the book Could it Be Autism?), they aren't just getting it wrong, with no motive for it. They are, in fact, creating demand for their product, just like advertisers do.
This doesn't mean society's attitudes towards difference aren't part of it. They are. The very reason these dire threats carry so much sting is because people are scared of disability. And they also feed into this, in that such threats make people even more scared, but I know that fear of disability came first. In fact, in the 1800s, the 'experts' played a much more positive role, counseling against things like keeping your disabled son locked in the attic and saying 'we can teach them something' (see On Some of the Mental Affections of Childhood and Youth, by John Langdon Down). That worked to bring them into their role of treating and educating developmentally disabled people. Now they're doing something else to maintain and build that role.
And while I don't know what the 'experts' are thinking when they do this, I think many of them are well-meaning. This might, in fact, be unintentional, be them simply repeating what they've been taught from outdated case reports of institutionalized and neglected or just simply unusually severe cases, and comparing those reports with the children they've seen with treatment. But in some cases, it could actually be intentional.
What made me realize this was my father's obsession with Westerns (I'm not sure why, he always criticizes them as poorly written, but he likes to read them), because he happened to mention that many doctors in those stories would exaggerate the severity of their patients' conditions so that when what they predicted didn't come true, their treatment would get the credit. And when a child who was described as echolalic and noncommunicative (as those terms are used, not always accurately) at 5 years old develops communicative speech and isn't institutionalized, if parents knew that Leo Kanner's follow-ups back when psychoanalytic treatment was in vogue found that outcome to be relatively common for kids who were echolalic at 5, they wouldn't be as grateful to the ABA therapists as they'd be if they'd been told their child would still be echolalic and noncommunicative as an adult.
This also explains the tendency for parents to actually view their children more negatively after diagnosis. Although parents who misinterpreted troublesome autistic behavior such as literalism or sensory overload as defiance or manipulation often view their child more positively after they are diagnosed, many parents actually viewed many of their children's differences fairly well pre-diagnosis. One parent, in a book I read, talked about how she though her kid was very focused, organized and intelligent - after diagnosis, she interpreted the same behaviors as indicating overfocused attention, repetitive play and splinter skills. It may be partly an accurate shift in expectations, since a non-autistic gifted child typically does better than an autistic child, but partly it's that such behaviors are overtly recategorized and relabeled, even when both labels are equally accurate or the pre-diagnosis one was more so. Cute little quirks suddenly become signs of a disability (another example, in Her Name is Montel, is when Montel's father finds out her odd catlike cry is a sign of Cri-du-Chat Syndrome).
Here are what I see as the major components of how the 'experts' create panic and sell their therapies:

• unrealistically negative prognosis - such as the 90% institutionalized quote. This can occur without any of the other features in doctors who aren't selling any treatment, but often goes along with promises of miracle treatments to change that prognosis.
• reframing neutral or positive traits as negative - as seen above in the shift from seeing a long attention span to seeing overfocusing.
• creating urgency - 'you can't even wait two months'. This means that parents do not have a chance to think through what they are doing before they do it.
• rosy promises of the treatment - such as, in ABA, the repetition of Lovaas's 47% cured statistic without explaining how Lovaas defined cure, how his treatment differed from modern ABA and the lack of independent replication or evaluation of his 'cured' cases.
• a theory that is never studied, changes when challenged, or both - this is also seen in ABA with the repetition of the neuroplasticity theory (ABA changes the brains of children so dramatically as to erase or reduce autism) in the absence of any study, or in the ever-changing ways the anti-vaccination movement finds to blame vaccines for autism.

(Can you think of any others? I'm sure I'm missing some.)
This shift in my viewpoint makes me more sympathetic to mothers, and also highlights the importance of critical analysis from multiple perspectives. I naturally tend to loook at autism from the perspective of an autistic person, while my mother sees it from the perspective of a parent of an autistic kid. Both of those perspectives, combined with critical analysis of the messages society is sending, give useful and enlightening interpretations that together can give us a more complete picture of what is going on.

Kanner autism

I hate how so many people misrepresent Leo Kanner's view of autism. They do it with Asperger's article, too, but at least they have the excuse that it's in another language (since the ones I know about are all English speakers). So I'm going to debunk several such claims.

"(The prevalence of classic Kanner autism, which is associated with moderate mental retardation, has not increased over the years.)"
http://books.google.ca/books?id=teMnqLotDm0C&pg=PA514&lpg=PA514&dq=Kanner+autism&source=web&ots=ra4jEJTOMr&sig=zNkdyNXmoZSF_fFIlw_e_vDivzw&hl=en

"Asperger, unlike Kanner, included people who had average to high IQs in his definition"
http://www.cbc.ca/news/background/autism/

In his 1943 article Autistic Disturbances of Affective Contact, Kanner said:

"With the non-language items of the Binet and Merril-Palmer tests, she [case 6, Virginia S.] achieved an IQ of 94. 'Without a doubt' commented the psychologist, 'her intelligence is superior to this'"

"A Binet test was attempted ... He [case 8, Alfred L.] finally complied in most instances in a manner that clearly indicated that he wanted to get through with the particular intrusion; this was repeated with each individual item in the test. In the end he achieved an IQ of 140." [Note: Alfred L and Virginia S were the only two children who cooperated enough for an IQ test.]

"Even though most of these children were at one point or another looked upon as feebleminded, they are all unquestioning endowed with good cognitive potentialities... The astounding vocabulary of the speaking children, the excellent memory for events of several years before, the phenomenal rote memory for poems and names, and the precise recollection of complex patterns and sequences, bespeak good intelligence in the sense in which this word is commonly used."

So clearly Kanner described children with average and above average IQs. Nowadays, the less cooperative children would likely have been tested and their refusals interpreted, robot-like, as wrong answers, just like my autistic friend who was declared profoundly delayed because he didn't cooperate at all with the test. Personally, I think Kanner's way, of declaring them 'untestable' and observing spontaneous signs of their abilities, is more fair.

"Most children and young people with Kanner syndrome will have moderate or severe learning difficulties and up to half may not learn to use spoken language."

http://www.southglos.gov.uk/NR/exeres/f55bba89-c85c-484a-b6ca-0165feaef454


"Kanners usually have a below-normal IQ
while Aspergers have a normal-above IQ
Kanners usually have a delay in speech
Aspergers usually don't"
http://www.autismspeaks.org/community/forums/archive/index.php/t-4438.html

The first part of these two statements is the same as the previous two innacurate statements. As for the second part, here's another quote from his 1943 article:

"Eight of the eleven children acquired the ability to speak either at the usual age or after some delay." [Of the speaking children, at least 5 spoke their first words before age 2, and at least 3 were using sentences by age 3.]

Although communication impairment, such as echolalia and not using speech communicatively, was present in all of Kanner's cases, most learned to speak, many at the usual age.

"Kanner’s Syndrome is often the lowest functioning end of the disorder, and these children (and adults) tend to be very drawn into themselves and have extremely limited communication skills."
http://ezinearticles.com/?What-Are-The-Different-Autism-Types-in-Children&id=510099


"Kanner described children who were severely affected. His description, and the downbeat prognosis persisted for the next 30 years."
http://www.patient.co.uk/showdoc/40000711

Regarding low functioning, Kanner's highest functioning case was Donald T., who in his follow-up in 1971 was described as such:

"Since receiving his AB degree in 1958, he has worked as a bank teller. He is satisfied to remain a teller, having no real desire for promotion. He meets the public there real well. ... He takes very little part in social conversation and shows no interest in the opposite sex. While Don is not completely normal, he has taken his place in society very well, so much better than we ever hoped for. If he can maintain status quo, I think he has adjusted sufficiently to take care of himself." [He wrote another article in 1972 giving case descriptions of several high functioning autistics.]

The prognosis was originally described in 1943 as:

"Five of our children have by now reached ages between 9 and 11 years. Except for Vivian S., [sic] who has been dumped in a school for the feebleminded, they show a very interesting course. The basic desire for aloneness and sameness has remained essentially unchanged, but there has been a varying degree of emergence from solitude ... Between the ages of 5 and 6 years, they abandon the echolalia and learn spontaneously to use personal pronouns with adequate reference. Language becomes more communicative, at first in the sense of a question-and-answer exercise, and then in the sense of greater spontaneity of sentence formation. ... Between the ages of 6 and 8, the children begin to play in a group, still never with the other members of the play group, but at least on the periphery alongside the group. Reading skill is acquired quickly"

Kanner made his opposition to institutionalizing autistics clear, and predicted poor outcomes for them, but if cared for in their own or a foster home, he predicted they would improve. A few would become high functioning enough to live and work independently, and those who didn't could still contribute.

"Kanner regarded autism as a consequence of harmful childrearing practices."
http://www.utoronto.ca/writing/paraphrase.html

And here they confuse him with Bruno Bettelheim, it seems. From his 1943 article:

"In the whole group, there are very few really warmhearted mothers and fathers. ... Even some of the happiest marriages are rather cold and formal affairs. Three of the marriages were dismal failures. The question arises whether or to what extent this fact has contributed to the condition of the children. The children's aloneness from the beginning of life makes it difficult to attribute the whole picture exclusively to the type of the early parental relations with our patients. We must, then, assume that these children have come into the world with innate inability to form the usual, biologically provided contact with people, just as other children come into the world with innate physical or intellectual handicaps. If this assumption is correct, a further study of our children may help to furnish concrete criteria regarding the still diffuse notions about the constitutional components of emotional reactivity. For here we seem to have pure-culture examples of inborn autistic disturbances of affective contact."

And in his follow-up:

"As for the all-important matter of etiology, the early development of the 11 children left no other choice than the assumption that they had 'come into the world with an innate disability to form the usual, biologically provided contact with people.' ... One can say now unhesitatingly that this assumption has become a certainty. Some people seem to have completely overlooked this statement, however, as well as the passages leading up to it and have referred to the author erroniously as an advocate of postnatal 'psychogenicity.'"

So even in the 1970s, it was already going on. People mischaracterized Kanner's words even back then. But back then, he could counter them.
Lastly, I couldn't find a specific quote, but I've read of children who developed normally until 18 months or so and then regressed being referred to as having 'Kanner autism'. Only one of Kanner's cases showed any regression, Richard M. (regression in pre-speech skills) but before his regression, he was described this way:

"The mother, in comparing her two children, recalled that while her younger child showed an active reaction to being picked up, Richard had not shown any physiognomic or postural sign of preparedness and had failed to adjust his body to being held by her or the nurse."

Kanner emphasized that these children were all noticeably abnormal in early infancy, commenting that they could not be called 'withdrawn' because they'd never been connected in the first place.

Nearest book

David Hingsburger was tagged for something awhile back. You take the nearest book, go to page 123, and type up three sentences. I'm not sure, from the instructions, if the sentences are meant to be sentences 5, 6 and 7 or 6, 7 and 8. Anyway, he said people could tag themselves if they wished, rather than him tagging people. So I've tagged myself.
Nearest book is the abc of CHILD CARE, by Allan Fromme, Ph.D. It was first published in 1960, but my copy is the 4th edition, published in 1975. Since I'm not sure which 3 sentences to quote, as described above, I'll quote 4 instead.

"b. If we are fortunate enough to have our own outdoor play area for our child, it is worth equipping it in such a way as to attract other children. Although this may sound extravagant, it is economical in the long run to have a sand box big enough for several children, with enough sand toys for all. One outdoor swing is never as effective as two or three. A place to play, indoors or out, where children are not constantly nagged about the mess or noise they are making is in itself attractive enough for children to want to return to of their own accord." (In a list of suggestions on improving your child's friendships.)

Now, that's not one of the really interesting parts of the book, so I'll quote a few of the more interesting (accurate or not) parts:

"There is no such thing as an aggressive child who also feels loved. Children who are habitually and openly overaggressive are the very ones who baffle their parents the most by their extravagant if infrequent demonstrations of thoughfulness, love, affection, and begging for forgiveness. ... Superficially, of course, we assume that we all love our children and that therefore none of them should be aggressive. No doubt we do love them, but it is equally true that we don't always put it in evidence sufficiently clearly for our children to feel our love. A child, for example, doesn't see our love when we scrub the dirt off from behind his ears. It is equally true, too, that in addition to the love we have for our children, we frequently feel annoyed, irritated, offended, impatient, and even desperate about them. Without realizing it, we sometimes express these feelings very much more dramatically and clearly than we do the more tender sentiments of love."

There are aggressive kids who act that way for reasons other than feeling unloved. Although many of those kids end up feeling unloved, it's simply because many people don't act loving towards an aggressive child, rather than because feeling unloved makes them aggressive. Apart from that, this statement is very true. Many aggressive kids act that way because they feel unloved, and being loved doesn't necessarily equal feeling loved. With autistic kids, especially, they are more frequently corrected and redirected. They also hear parents describing them as having a problem that may have stolen their child, be trapping their child, be an enemy that must be fought, or other forms of nasty imagery about autism. Those statements might be less harmful if the child's perception matched them - for example, if they really did feel trapped - but most autistic children don't naturally feel trapped by their own brain style. (Some feel trapped by movement difficulties, but even that need not be seen that way.) The child often wonders 'if you knew this was who I really am, would you hate me?' and feel your expression of love isn't real.

"The child can be spared considerable confusion, in many instances, if the divorce is as complete for him as it is for his parents. His father's visits almost always lead to additional rejection when they are eventually discontinued. The younger a child is at the time of divorce, the easier it is for the man to divorce himself from his child also. Although this may not be easy, in any case, and is not supported by the law, it is merely a recommendation worth considering. The child should be adequately prepared for his father's departure in either event."

"Most important of all, replace your child's father as quickly as possible by remarriage. Don't try to be a mother and a father to your child. You can't do it. You'll remain a mother, make your child excessively dependent on you, and confuse the masculine and feminine roles in life for him. The longer you put off remarriage, the more difficult it becomes for you and the less easily do children accept the idea. Remarry - it's the best thing you can do for yourself and your children."

"In the case of the death of a child's mother or father, the recommendations above still pertain. However, the most important thing one can do is to supply a substitute as soon as possible. A child's daily physical care is the paramount issue. No woman can be father and mother to a child alone, nor can any man expect to perform the functions of mother and father himself. The greater problem, of course, is the death of the mother. Ideally, some immediate substitution should be made. A maid or grandmother are good temporary solutions. Remarriage is the best permanent one."

All of this advice is precisely the opposite of what is really best for the child. Absentee fathers are a big problem, and this should not be encouraged unless the father is abusive. Regarding remarriage: a) single parenting is not a big problem, provided they have (and use) a good support system, b) you can't be choosy if you're in a hurry to get married, especially since many people don't want to be stepparents, and therefore are more likely to make a poor choice, and c) children need time to adjust and grieve (especially in the case of death rather than divorce) and even after many years may be unable to accept a 'substitute' (in fact stepparents must never be portrayed as a substitute, because they are not the same person as the child's parent). The only children to whom this advice wouldn't necessarily be damaging are children under 2, who will be fine as long as they have good parenting (however, making a poor choice in spouse or having unresolved grief can adversely affect them long term).
The other advice they have for children in case of death is also damaging, because it encourages the parents to minimise it and ignore or suppress the child's grief, in the idea that children grieve not because of their own loss but rather modeling from parents, and that grieving is unhealthy for children.

"Under no circumstances is spanking your child the best technique of discipline. No doubt you have friends who feel differently about this. Certainly you must have heard them say, 'Why, when my child behaved that way, I gave him a good spanking and that was the end of it.' They're telling you the truth, too, in their naive way. Probably it was the end of it - from what they could tell.
But were they in the best possible position to make this diagnosis? They were interested in a specific result and got that result, but do they know what else happened in the thought, feeling or behavior of their child not obviously or immediately related to the very specific misbehavior they were trying to correct?
Spanking a child is effective only if it hurts him - hurts him enough so that he becomes afraid, not only of the thing he might have done, but of you. ... Spanking our child has still another unfortunate effect upon him. Just as he learns to fear us as a result, he will also learn to resent and hate us. Since our child also quite naturally loves us, we place an enormous burden of conflict upon him by infusing his feelings of love with those of fear, resentment and hate as well."

This seems to me to be very accurate, not only about spanking but any kind of aversive. Some aversives don't exactly hurt, but any effective aversive is unpleasant enough that the child will fear getting it. You can fear eating something disgusting, for example, even though the unpleasant taste isn't painful.

[children up to about 10 don't mourn much unless parents overburden them with their own grief]

Whose Side Are They On?

According to many parents of autistic kids, at least those who know the history of autism, psychoanalysts were 'the bad guys'. Many also hail early behaviorists as heroes. Certainly, they were much kinder to parents. Bruno Bettelheim, in his book The Empty Fortress, said that the difference between Nazi prison guards and mothers of autistic kids was that the mothers got at the children from a younger age (Bruno Bettelheim was a concentration camp survivor, and appears to have drawn extensively from that in his work). In contrast, in an interview I found with O. Ivar Lovaas, he said: 

"I can tell you that the parents that we work with are very nice people. We get to know the parents as people, and when you do that you find that there is no reason to believe that they produce autism. But a lot of parents still think that it must be their fault somehow. They have heard that the parents of autistic children do not express love adequately, so they bend over backwards to be loving. What they get for their trouble is even more bizarre behavior � the child smears his feces on the walls, bites his parents, and has violent tantrums. The parents are afraid to punish them for these acts because they have been told that the child behaves this way because he feels unloved, so if you punish him you are only making him worse. But this is all nonsense. And this theory has made a lot of parents feel terribly guilty and made the autistic child get worse instead of better." 

It's obvious which attitude parents would prefer. But if I was an autistic child in the 1970s, I'd much rather receive psychoanalysis than ABA, even though it would be worse on my parents (though admittedly not all psychoanalysts were quite as bad as Bruno Bettelheim). Here's why: 

"You see, you start pretty much from scratch when you work with an autistic child. You have a person in the physical sense - they have hair, a nose and a mouth - but they are not people in the psychological sense. One way to look at the job of helping autistic kids is to see it as a matter of constructing a person. You have the raw materials, but you have to build the person." 

(Ivar Lovaas, in the above-mentioned interview)

In contrast, psychoanalysts typically viewed the autistic child as a person and assumed their behavior was meaningful and important in some way. Behaviorists consider behavior meaningful, but in a very limited and simplistic sense of receiving a reward of some kind, and they don't question whether abnormal behavior should be reduced. Psychoanalysts ideally hoped their patients would become normal, but they were careful not to remove important methods of self-expression unless the person had better ways of expressing themselves (and even then, they were careful about it). In general, the treatment was much kinder. Psychoanalysts worked on building connection and understanding the patient. With higher functioning, adult patients, this was generally sitting or lying comfortably while saying whatever came to mind - 'free association' - but with children, especially if they had limited verbal skills, it was basically play therapy. The book Dibs: In Search of Self is a good illustration of this with a boy who probably was autistic (they call him emotionally disturbed). Here's Lovaas describing how he treated autistic kids: 

"Spank them, and spank them good. They bite you and you just turn them over your knee and give them one good whack on the rear and that pretty well does it. This is what we do best; we are very good at controlling these kinds of behaviors. This is also the way we handle self-destructive behavior." 

"One day I was talking with her teacher and Beth began hitting her head against the edge of a steel cabinet. She would only hit steel cabinets and she would only hit them on the edge because, you see, she wanted to draw blood. Well, I think because I knew her so well, I just reacted automatically, the way I would have with one of my own children. I just reached over and cracked her one right on the rear. She was a big fat girl so I had an easy target. And I remember her reaction: She turned around and looked at me as if to say, "What the hell is going on? Is this a psychiatric clinic or isn't it?" And she stopped hitting herself for about 30 seconds and then, you see, she sized up the situation, laid out her strategy and then she hit herself once more. But in those 30 seconds while she was laying out her strategy, Professor Lovaas was laying out his. At first I thought, "God, what have I done," but then I noticed that she had stopped hitting herself. I felt guilty, but I felt great. Then she hit herself again and I really laid it on her. You see, by then I knew that she could inhibit it, and that she would inhibit it if she knew I would hit her. So I let her know that there was no question in my mind that I was going to kill her if she hit herself once more, and that was pretty much it. She hit herself a few times after that, but we had the problem licked." 

"We stay close to them and when they hurt themselves we scream "no" as loud as we can and we look furious and at the same time we shock them. What typically happens is this - we shock the child once and he stops for about 30 seconds and then he tries it again. It is as though he says, "I have to replicate this to be sure." Like a scientist. He tries it once more and we punish again and that is pretty much it. So we can cure self-destructive behavior - even long-standing, self-destructive behavior - in a matter of minutes." 

"How do you avoid having the child become afraid of you? Lovaas: That is a good question. No one punishes who isn't prepared to devote a major part of his life to that child. Nobody punishes a child who doesn't also love that child. As soon as you suppress self-mutilation you start building appropriate behaviors. You reward the child for doing other things instead of hurting himself." (It actually won't work - I lived with someone who was sometimes nice and sometimes mean and I was plenty scared of him.) 

Which would you prefer - someone playing with you and getting you to express how you feel, or someone hitting you, yelling 'No!' right in your face and zapping you with an electric shock device? Which would you prefer - being viewed as a person who is hurt and coping the only way they can, or as a physical person who is not a person 'in the psychological sense'? Psychoanalysis certainly had its problems, but it was by far better for autistic children than ABA.

An Insight Sadly Ignored

I'm not generally a supporter of Bruno Bettelheim, from what I've heard of him, but recently I found something he wrote that I really wish more people had followed.
In the American Journal of Orthopsychiatry, volume 26(3), pages 507-518, published in 1956, he said:

"All this would be quite easy to see if we would just listen carefully to what the schizophrenic children tell us, at least those who talk. They will let us know readily enough what kind of treatment they need..."

He then describes a case where a 'schizophrenic' girl told Anna Freud, her therapist, that she was a very different person in different situations and therefore Anna Freud really had a very limited understanding of her, seeing her in only one setting. Rather than listen, Anna Freud described it in this way:

"It struck me that here, disguised as a piece of 'technical advice,' we were offered some insight into the basic deficiencies of her ego structure. [and proceeded to give a long and convoluted interpretation which I will not quote here]"

He also has some interesting case studies, showing some issues still around today and probably more ignored now:

"A mother whose schizophrenic child lived at the School had been in prolonged psychoanalytic treatment. She was making good progress, but we felt that her influence on her child was so pernicious that they should remain separated. The mother's analyst thought that the mother needed to test her ability to be a better mother, and supported her in her insistence on a home visit. Reluctantly, we agreed to a visit of two weeks' duration. The child set fire to the parental bedroom while the parents were asleep there. No great damage was done and the parents viewed this as a childish prank. A year later, with the approval of her analyst, the mother again insisted on a visit. We were opposed, because the child, who was functioning quite well within the protected setting of the School, expressed great fear about what might happen on such a visit. Despite our objection the visit took place; then, while with his parents, the child died in a carefully contrived accident."

Murder of disabled children by their parents was certainly present back then. It chills me to think of what it was like for that child - clearly, he knew or suspected they would do something terrible to him. On the other hand, I'm glad that Bruno Bettelheim clearly views the killing of this child as a bad thing.

"Parents considered their boy feebleminded from the moment he was born. Since he supposedly did not understand, they spoke freely of how he ought to be put away, how he should never have been born. Autistic withdrawal led to his being sent to an institution for feebleminded children, where he was badly neglected and where he was often deprived of meals as punishment. This added to his conviction that his parents wished to kill him through starvation. He spent most of his first seven years in phantasies of how he would torture and kill others before they could kill him. (Such phantasies were typical among concentration camp prisoners.)"

This reminds me of Amanda Baggs' description of growing up with the expectation that she'd either be cured or institutionalized.
It saddens me to think that things like this were spoken about in the 1950s, and most people still don't get it. How long will it take before people start listening to us, respecting that we have just as much a right to life as anyone else, and recognizing that we are aware and being spoken in front of with hurtful statements hurts us too?

Strength in Abnormality = Deficit is Nothing New

One phenomenon I've noted is the tendency to try to interpret every way a disabled person differs from the norm as a deficit, even our strengths. The most well-known example of this is probably the Block Design peak in autism.
A number of studies found that autistics tend to have noticeable strength in Block Design, in some kids significantly better than normal (I once saw the IQ test scores for an autistic boy who had gotten the lowest possible score on Comprehension and Vocabulary and the highest possible score on Block Design). Not all autistics have Block Design peak, but it's extremely rare for a non-autistic to have significant Block Design peak.
The interpretation given to that was 'weak central coherence' - a deficit in perceiving the big picture, 'can't see the forest for the trees' cognitive style. In reality, most people, including autistics, do not naturally segment images into equally sized blocks but rather along color borders and using a bunch of extrapolation to estimate what the thing looks like in 3 dimensions. There have been a number of studies showing this, and no evidence has been presented to suggest this is vastly different in autism. So in order for anyone to do well on Block Design, they must force a different segmentation than is natural, something which someone with weak central coherence would have difficulty doing.
But the tendency to interpret a strength in a disabled person as a deficit is very pervasive. And just now I discovered it dates back at least to 1953, most likely earlier. In 1953, Margaret S Mahler and Paula Elkisch described a child, Stanley, considered 'psychotic', in the journal The Psychoanalytic Study of the Child, volume 8, pages 252-261.
Stanley was a strange boy. He cried whenever he heard a story 'When You Were A Baby' which he insisted on hearing, and reacted similarly to a number of other stories about babies. He would try to feed pictures of crying babies and played with a book called Fun With Faces, in which you could switch a baby's face from crying to not crying. While playing with that face he "threw up his stiffened and flexed arms, strained and tightened his arm muscles rhythmically in this position for some time, while twisting his head downward and to the left side. His face was bizarrely distorted with widely open mouth and protruding tongue."
Relevant to this post, he showed a remarkable memory. This was not interpreted in a positive manner. Rather, this is how they introduced their article:

"Parents of psychotic children frequently stress the fabulous memory these youngsters have. Closer examination of this phenomenon in severely disturbed children reveals that this seemingly positive ability actually expresses grave pathology of the ego in the most crucial and important mechanism of defense: repression."

In other words, Stanley had a deficit in forgetting!