Sunday, June 26, 2022

Are Babies Underestimated?

How much is impossible for young children, as opposed to just believed to be?

My baby, who is currently 6 weeks old, has on several occasions made hand movements that vaguely resemble signs. Several times she's made a movement that could be FOOD/EAT or HUNGRY. (More likely hungry, because I've signed that more in her presence.) And just today, she made a motion that could've been the sign MILK, also a sign I use frequently when communicating with her*.

In each case, when I responded as if the gesture was communicative, she reacted in the manner that would be expected if she was making a request. In other words, she seemed like she was signing to request milk, I gave her milk, she drank it and seemed happy.

But she's 6 weeks old! The earliest estimate I've seen for when a baby exposed to sign-supplemented speech might start to sign is 6 months, not 6 weeks. She should be still at least five months away from her first signs, right? And most likely more.

And of course there are alternate explanations. Maybe she's just randomly flailing. The gesture that could've been HUNGRY or FOOD/EAT is very similar to a common instinctive response to hunger in newborns - trying to suck on their hands. This is a behaviour my baby has also shown.

It's also possible that she's started hand babbling in imitation of my signing, but with no real communicative intent. She does like to imitate us, within her ability to do so. She'd be early for hand babbling - the VCSL says about 25% of 4 month olds can do it - but that's less remarkable than actual first signs.

Or perhaps she's been operantly conditioned, unintentionally, to associate hand movements with getting fed, even though she doesn't yet understand that specific hand movements have specific meanings. Certainly, I haven't noticed her appearing to sign in any other context than requesting food. Then again, there's nothing she's as urgently motivated to communicate about as that, and it's also the context I've ended up most consistently signing to her in, so it wouldn't be surprising for that to be her first signed communication function anyway.

And all this has me wondering - how do we know that it's impossible for a one month old to use linguistic communication? We just know it, right? And that means that if a one month old shows behaviour that, in an older child, would be taken as linguistic communication, it's interpreted differently because of the child's age.

But a lot of people "just know" that children don't even begin to develop bowel and bladder control until 18 months, and yet, in many cultures the average age at completing toilet training is younger than that. I've had my share of incredulity at telling people that I started potty training my child at 3 weeks, because so many people see potty training as a process that requires a mobile, verbal child who meets a set of "readiness criteria". 

Incidentally, I know fully continent disabled adults who don't meet the standard toilet training readiness criteria. Especially the ones related to walking and self-dressing. I even knew someone who had poorer motor skills as an adult than my baby does at one month, and yet was fully continent. Obviously, she needed help with the process of going to the bathroom, but she didn't need diapers.

I sought out Mary Ainsworth's book Infancy in Uganda because of her later advancements in the field of attachment theory, which built on her experience in Uganda. But in reading the book, I was struck not by the attachment behaviour (which was basically the same as how babies I've known in Canada acted at the same ages) but by the children's motor development.

You see, Ugandan babies, at least at the time of her study, regularly reached certain motor milestones far younger than the norms in Westernized countries full of European-descended people. This phenomenon has also been observed in Kenyan infants.

Another example is reading. I'm not trying to teach my baby to read, currently, but I have been considering it. The argument I've seen for it argues that sight word recognition is just as possible for young children as recognizing spoken words, provided that they are regularly exposed to text that is actually large enough for them to read with their immature eyes, and presented in real-life communicative contexts. I don't know if that's true. But I do know that, like toilet training, reading is often stated to require prerequisite skills that many people I know apparently didn't actually need.

Of course, disabled people are different from small children. Disabled people often have skill scatter, with some skills way ahead of others, so what they can do doesn't necessarily reflect on the abilities of nondisabled children who are similar in some of their abilities. However, they are informative about what really is or isn't a prerequisite, and that raises questions about nondisabled children who lack the same prerequisites.

And in general, I think people underestimate both how much variation there is in children's abilities, and how much the cultural context can alter early development - even when it doesn't have similar effects on later development (after all, there doesn't seem to be any lasting difference between children potty trained at different ages once they've all completed the process).

There's also a lot of people who clutch at theorized negative impacts of various forms of precocious development. I think this is mostly because they're defensive about their own children being slower than someone else's child, especially if that might be related to parenting choices. Even if the parents of the precocious child aren't in any way trying to claim superiority, some people will automatically react as if they are.

So, is my one month old actually signing? Maybe. I think there's reason to doubt it beyond just the widespread belief that language is impossible for such a young child. But I do think that we should evaluate her behaviour for itself, instead of presupposing what she's doing based on what children her age are widely believed to be capable of. And I certainly don't see any way that responding to hand gestures that might be requesting milk by giving her milk and talking about it could possibly harm her. Even if she's not actually signing yet, that response would help her learn to do so eventually.

* A typical commentary from me would be the following, spoken with the capitalized words signed as well: "Are you HUNGRY? Do you want MILK?" (Sometimes I'll also sign WANT.) Soon afterwards, I generally put the bottle to her mouth and see if she'll drink from it.

Sunday, June 05, 2022

Newborn Curriculum Goals - 3 week update

 So, my child is born now. In fact, she’s* three weeks old as of June 3rd.

In the past three weeks, I haven’t really been active online because I’ve been very focused on adjusting to the challenge of being a parent in a more direct, hands-on way than when she was in utero. However, I have been regularly noting down curriculum goals she’s met, as well as reorganizing some goals.

Life Skills


When I first discussed my newborn educational goals during pregnancy, the Life Skills category consisted only of four goals related to Elimination Communication. That’s been a bit complicated, but first, let me talk about two new goals I came up with myself, both related to Eating instead of Toileting.

  • Drinks from cup held to lips

  • Getting a decent latch and sucking persistently until no longer hungry

I added these two for two very different reasons. Drinking from a cup was something she was having unexpected success with, and latching onto breast was causing unexpected difficulty.

This and a couple items I'll discuss later also led me to create a new field in my curriculum database for noting concerns related to a curriculum goal. That way, I can more easily track the items she's having unexpected difficulty with or that might be linked to potential underlying issues that make them harder for her.

When she was first born, my child immediately latched onto my breast and nursed quite well, but after that initial success, she proved to be extremely difficult to breastfeed. Although I had plenty of lactation assistance in the hospital and was repeatedly assured that I was doing everything right, she wouldn’t, or perhaps couldn’t, cooperate. She’d start to latch and then turn her head away, she’d recoil from the nipple, she’d act like she’d latched but instead close her mouth and suck on her lip or tongue, she’d try to suck on her fingers and get her hands in the way, she’d latch with her tongue above the nipple blocking her efforts to suck… It seems like there’s a myriad of ways that it’s possible for this baby to get nursing wrong.

After a scare with low blood sugar (due to my gestational diabetes), when a nurse offered me a bottle of formula just to make sure she was fed, I accepted. It was simultaneously a big disappointment and a huge relief, watching her eagerly suck down that bottle of formula. I may not be able to nurse my baby, but at least I can feed her.

Since then, I haven’t given up on nursing, though I haven’t been trying to latch her as much as I probably should. It’s really discouraging to try and fail, so I usually go for a bottle first, but I’ve been trying to do at least one latch attempt each day. I’ve also been exploring resources online for possible theories about why she’s struggling to latch (my current theory is oral motor issues), and I’m looking into hiring a professional lactation consultant to try to help with breastfeeding.

In the meantime, we’ve fed her a mix of formula and expressed milk (though now that I’ve gotten an electric breast pump and built up my supply it’s looking like we’re not going to need to use formula anymore), using either a syringe (though unfortunately our syringe is broken now), one of two different bottle designs that we have, or, bringing us to the other goal, I’ve occasionally fed her directly from a cup.

She can’t drink more than a small amount from a cup at a time - if I pour too much, she’ll choke and spit it out. However, she can finish off the last bit that got caught on the rim of the nipple if I remove the nipple and carefully offer her the bottle as an open cup. I also use this method sometimes to give her vitamin D supplements, since she’s supposed to get a drop of vitamin D supplement every day. I honestly wasn’t expecting to be able to cup-feed a newborn, but I tried it once and it worked, so I’ve kept doing it.


As I’ve mentioned above, prior to my child’s birth, I planned on doing elimination communication - a toileting method where you provide children with opportunities to eliminate in a “toilet” (using the term loosely - could be an actual toilet, a potty, a sink, or anything like that) instead of their diaper, long before the age they’re considered ready for conventional potty-training.

However, initially, the whole process of parenting was so overwhelming, and I realized that I basically had no idea how to make EC actually work in practice, so I tabled the idea - even going so far as to reclassify the four EC goals as starting at 3 months instead of birth.

On June 3rd, however, because my child has a diaper rash, I’ve decided to try to make a tentative start on elimination communication (and also started using cloth diapers, which I'd purchased but not tried using until today). And as such, I’ve moved these four goals, drawn from the Standards Based Life Skills Curriculum, back to the 0-3 age bracket:

  • Cooperates with being placed on toilet

  • Toilets on a scheduled time with prompt

  • Urinates in toilet

  • Voids bowels in toilet

Of those, the last one, voiding bowels, is the only one she’s made any progress on so far. She has a tendency to give very clear signals when she's pooping, and also tends to poop a bit, wait, and then poop some more. This habit has sometimes resulted in either soiling a diaper immediately after being changed or pooping on the changing mat mid-change, but it occurred to me that it's also an excellent opportunity for EC.

So, today, when she pooped her diaper and then started acting like she was working on more poop, I took her to one of the many spare sinks in our office (my mom runs a family business we all work in, and the office building used to be a medical clinic so there's a lot of sinks). I've changed her diaper in the sink a few times - this time, I just waited with her undiapered in the sink until she did her next bit of pooping.

It's not the first time she's pooped without a diaper on, but it's the first time she did so when I actually wanted her to, so it's progress. Of course, it wasn't intentional on her part, but that doesn't matter in the early stages of EC.

She was not cooperative, either - in fact, she was crying and struggling, as she usually does with most diaper changes. But I have some ideas on how to make the experience more pleasant for her next time. Specifically, I'm going to run warm water in the sink before I put her in it, so she's not sitting on cold porcelain. I think that was her biggest objection to the process. So hopefully we'll have some progress on the cooperation goal soon, too.

Motor Development


These items were drawn from the Montessori Scope and Sequence:

Lifts head while being held (MD.E.1)

Raises head while lying on stomach (MD.E.2)

Masters control of the head (MD.E.3)

Supports upper body with arms while lying on stomach (MD.E.4)

Stretches out and kicks legs (MD.E.5)

Pushes down with legs when held above a hard surface (MD.E.6)

She was kicking and stretching her legs a lot in utero, much to my discomfort in the third trimester! She's continued to be very active with her legs since birth, especially during tummy time. She also loves to push her feet against things, and shows a definite stepping response.

Head control seems to be a strength for her. While she certainly does still need help holding her head steady, especially when she's being moved around, I first saw her lift her head deliberately during the first skin-to-skin contact after her birth, and both during cuddling and during tummy time, she regularly lifts her head briefly to reposition it when she wants to look in a different direction or get more comfortable. I'm sure it won't be long until she has a steady head.

She's not pushing up with her arms yet. Currently, in tummy time, her arms are pretty much the only body part she doesn't tend to move. I am not particularly concerned about this, I think this is one of the more advanced goals in this group.

Hand Control

Hand Control goals:

Opens and closes hands (MD.HC.1)

Brings hand to mouth, explores hand with mouth (MD.HC.2)

Instinctive prehension evident in grasping adult finger or object offered (MD.HC.3)

Begins to observe own hands (MD.HC.4)

Swipes at objects (MD.HC.5)

Both of the two goals that were possible to observe on ultrasound were things she'd definitely started doing before birth. Since birth, she's mostly only brought her hand to her mouth when hungry, and often this leads to sucking on her fingers. The nurses at the hospital figured she probably sucked on her fingers prenatally, too, so it's likely that the times I saw her bring her hand to her mouth on ultrasound were related to finger-sucking.

She grasps adult fingers consistently, and also grabs grandma's hair. During feedings, she's also started to grab the bottle, and sometimes is able to help hold it steady. She also swipes at her high-contrast tactile books, which are crinkly black and white books I bought that have so far been her favorite toys. I discuss them more later on in terms of visual response.


Hearing & Understanding

Still with the Montessori goals, here's the ones related to Hearing and Understanding:

  • Responds to loud sounds in environment (L.H&U.1)

  • Calms or smiles in response to human voice (L.H&U.2)

  • Recognizes voice of parent or primary care-giver (L.H&U.3)

  • Moves eyes towards direction of a sound (L.H&U.4)

  • Notices objects that make a sound (L.H&U.6)

  • Responds (pays attention) to music (L.H&U.7)

  • Turns head towards direction of a sound (L.H&U.10)

And let's throw in the Visual/Auditory: Auditory item, since it seems more relevant here:

  • Reacts to different sounds (VA.A.1)

As I mentioned before, in utero, I noticed strong and clear responses to sounds from outside. My child kicked in response to loud noises, cat purring, and music, and also in response to her grandmother's voice but no one else's.

So I have been very surprised that her hearing has actually been an area where concerns have been raised after birth. During her newborn hearing screening, she failed in her left ear, and she's due for a follow up hearing test later this month. I've also found that she tends not to react as strongly to ambient noise as she did in utero - she sleeps through pretty much any noise, and she's shown no interest in music.

She has, however, startled a few times at loud, sudden noises, and she still seems very interested in her grandmother's voice. She also sometimes orients to sources of sounds, though this is still inconsistent.

Notably, despite her hearing results, she has shown response to left-sided sounds. For example, once when I was overwhelmed because she'd been crying a lot while I was home alone with her, I called up my mother on the phone, and she started talking to the baby soothingly. Even though her right ear was pressed firmly against my arm and the phone was to her left, my child quieted and looked at the phone as her grandmother was talking to her. (Indeed, both times I've recorded her calming in response to human voice, it's been her grandmother. I don't know what it is about her voice, but my baby definitely responds more to her speech than anyone else's.)

She hasn't yet moved her head to look at sources of sounds (despite moving her head to look at interesting sights, as I discuss below). And she hasn't shown any clear responses to music since she was born, only prenatally. But otherwise, she's shown progress on all the hearing items, despite the concern raised by her newborn hearing screening. I have no doubt that she can hear - the question is, can she hear well enough to be considered fully hearing as opposed to hard-of-hearing? We'll know more soon.

In the meantime, this just cements my conviction that I want her multilingual language environment to include ASL as well as spoken languages. If she is hard-of-hearing, ASL could be a very important language for her to know, even if her hearing is good enough to use speech fluently as well.

I researched one-sided deafness when she first failed her hearing screening, and it seems that the biggest concerns tend to be noisy environments and people trying to talk to them from the wrong side, and I could see ASL code-switching being a useful strategy to deal with those situations. It could also be really helpful if she has hearing fatigue, as many hard-of-hearing people do, where situations that require listening carefully are exhausting and lead them to need rest afterwards. Of course, to make effective use of ASL in those situations, I'll need to improve my own ASL fluency as well, which is an ongoing goal I've been working on. (She's not the only one here with educational goals!)

And if it turns out it was just some amniotic gunk in her ear that's since cleared up and she's fully hearing, well, there's a lot of benefits to learning ASL regardless of hearing status, too.

Speaking & Listening: Speaking

Here's my goals for this age period in the area of Speaking:

  • Communicates pleasure through cooing sounds (L.S.2)

  • Indicates different needs through different cries (L.S.3)

  • Smiles when seeing a familiar person (L.S.4)

  • Uses body language to communicate needs (L.S.13)

She's been making pretty good progress on these goals. She has different cries and nonverbal cues for hunger as opposed to pain/discomfort (usually related to the need to burp or poop). Interestingly, I was able to distinguish her cries subconsciously before I could do so consciously - before I could tell hunger cries from discomfort cries consciously, I noticed that hunger cries induced letdown of milk and discomfort cries didn't, and used my breasts' response to her cries to help me figure out how to calm her. As for nonvocal cues, hunger is associated with rooting and mouthing/sucking on things, and abdominal discomfort is associated with arching her back, grimacing, and writhing side to side.

Pleasure is less consistently signalled so far. She has made cooing or burbling sounds sometimes when she's calm and contented, and she smiles occasionally while drinking milk, but hasn't shown any social smiles yet.

Next, this area also includes goals I've drawn from The Pragmatics Checklist, an assessment of social communication skills in Deaf children that I came across. As I mentioned previously, although this checklist was used with 2-7 year old children, several of the easier items had been mastered by all of the hearing comparison group even at the youngest ages, so I figured out appropriate ages for them based on my research on child development. The following items ended up in this age band:

  • Makes requests nonverbally (1-1)

  • Requests help nonverbally (5-1)

  • Complains nonverbally (13-1)

All of these she's definitely been doing. She cries and roots around when hungry, and also cries and writhes when she's physically uncomfortable. It's unclear how much communicative intent she has - in other words, it's hard to tell if she's crying just because being uncomfortable or hungry makes her want to cry or if she's actually trying to tell us how she's feeling by crying. But she does briefly calm and make eye contact sometimes when I touch her or pick her up when she's crying, which makes me think she might be expecting me to fix whatever is bothering her.


As with The Pragmatics Checklist and the Standards Based Life Skills Curriculum, the Self Determination Goals and Checklists also was designed for older children with disabilities, and I've adapted the ages based on developmental research. Only two items ended up being relevant for this age range, and one of them, "Have a way to communicate that they need help?" is redundant with The Pragmatics Checklist item 5-1 above. That leaves only one item:

  • Have a way to communicate they need a break?

The first time I noticed my child showing signs of needing a break was during the 20 week anatomy ultrasound, which, for those of you who aren't well versed on the usual pregnancy ultrasound schedule, is a standard screening test performed roughly around 20 weeks gestation where the ultrasound tech attempts to get a detailed look at basically all of the baby's major organs.

It's a very long ultrasound, and ultrasounds are believed to cause vibration that the baby inside can detect. My child seemed to find it stressful, since towards the end, she'd decided to turn away from the front and curl up with her arms crossed in front of her chest, resulting in the ultrasound tech not getting a good look at her heart and one of her arms.

After birth, she's also told me when she needs to stop tummy time or other physically effortful positioning by whining and struggling.

Sensory Development

Visual/Auditory: Visual

Here's the Visual items from the Montessori Scope and Sequence for this age:

  • Displays interest in black and white mobiles. [or other visual targets] (VA.V.1)

  • Follows moving objects with eyes (VA.V.2)

  • Recognizes familiar objects and people (VA.V.3)

She is very interested in black and white things. I don't have a black and white mobile for her, but I do have some black and white tactile books, made of some sort of crinkly cloth with interesting textures and some bells inside some of the pages. But she's not that interested in the auditory and tactile elements of the books yet - what she cares about is the simple black and white pictures on each page. She loves to look at them and reach for them, and I've used them to keep her calm during diaper changes (even with a diaper rash!) as well as to motivate head movements in tummy time. I've also Googled high contrast pictures to distract her when she's upset, and gotten her to play with handmade crocheted colored balls and cups by putting the black ball in the white cup and vice versa.

Visual Communication

I found a scale for assessing sign language development known as the Visual Communication and Sign Language Checklist. Two items are relevant at this age, one of which, item #15, is redundant with the Montessori Speaking item L.S.4 above, so that leaves this one:

  • Looks at the visual environment with alertness (item #14)

She's been getting more and more interested in looking at things in the three weeks since she's been born. During tummy time, she looks around a lot, especially at her high contrast books. She's also shown interest in watching the screen while me and my brother are playing video games together as one of us is cuddling her, stared out the window during car rides, and watched my hands and face with interest as I practiced ASL while playing with a children's educational app (Khan Academy Kids) in her presence.

Advanced Skills

There's also two items I've been expecting to be working on later, but which she's shown some notable progress on already. Both of these are from the Montessori Scope and Sequence:

  • Begins to roll both ways (MD.E.8)

  • Scoots along floor using arms and legs to propel body forwards (MD.E.10, 3-6 months)

  • Begins to show preferences in the tastes of food (GOT.G.2, 6-9 months)

No, she's not rolling or crawling yet, and probably won't be for awhile, but she's definitely trying. In tummy time, I've noticed her making movements with her legs that look like a crawling pattern, but without the strength and coordination yet to actually gain traction. And when she's on her back, she often tries to roll to her front, getting stopped only by the fencing reflex. This kid wants to move, that's for sure! I suppose that tracks with how vigorously and frequently she moved in-utero.

As for the food preferences item, I was expecting this to only be relevant once she started getting solid food. After all, if things had gone according to my plans, she'd have only had breastmilk before 6 months old. But she's had formula, too. And as a result, she's had the opportunity to compare two different-tasting foods - breastmilk vs Similac. And my mother has noticed that her facial expressions are less enthusiastic when she's being fed Similac vs my pumped milk. (I agree with her preferences, btw. Similac is gross-tasting, whereas breastmilk is sweet and tastes like almond milk. Meanwhile colostrum is like a cross between sweat and honey.)

* My child is AFAB, and since most AFAB individuals prefer she/her pronouns, I’ll use those until/unless my child indicates a different preference. I considered sticking to they/them pronouns, as I’d been using before I knew her sex, but it’d be challenging within my community context and there’s only a small probability that the choice would make an important difference to my child’s wellbeing. I’d rather know this is a fight that will matter to my child before I pick it. However, although I chose not to use they/them pronouns for my child, I heartily encourage others to do so, because each person who makes that choice normalizes their use a little more.

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Thursday, March 17, 2022

Optional D&D Roleplaying Rules for Compulsions

I came up with these rules awhile back, as a way to help me roleplay some of my own characters, and recently put them to use for the first time in a session and they worked great. So I'm going to explain the rules, and then talk about how that session went.

For characters that are supposed to be affected by compulsions that make them want to behave in ways that are incompatible with their moral code or who they see themselves as, which are supposed to be difficult but not impossible to resist, it can be hard to figure out a way to properly represent these in-game, if you want more guidance than simply roleplaying the effect yourself. This can be especially problematic when the effect is assigned by the DM to a PC, such as when a magical effect causes a PC to gain a new flaw.

For simple, immediate impulses, making a Wisdom saving throw (DC set by PC) to resist the urge to immediately do a thing could be appropriate - eg, while a hungry vampire is hugging a living humanoid, they might make a Wisdom saving throw and on a failure make a bite attack against the person they're hugging. Similarly, if an alcoholic has a cup of alcohol in front of them, they might make a Wisdom saving throw or take a swig.

However, for actions that take multiple rounds, and especially ones that take planning, it's a lot harder to represent them with a single Wisdom saving throw. Eg, for an alcoholic who doesn't happen to be right next to an alcoholic beverage, how would you represent the process of them going to a bar, ordering a drink, and drinking it, despite their desire to quit drinking?

In 3.5, many of these effects are represented by ability damage - the Book of Vile Darkness has ability damage due to withdrawal from addiction, and the Libris Mortis has ability damage for undead with an unfulfilled desire or need to feed on the living. However, this has always felt unsatisfying to me. For addictions, it's quite plausible that a character could go into withdrawal, become incapacitated, and then recover, without ever feeling like you might not be able to prevent your PC from seeking out their addiction. Libris Mortis has the Inescapable Craving type of undead hunger result in uncontrollably seeking out the object of their hunger if they reach 0 Wisdom, but it's no harder for a wraith at 2 Wisdom to resist draining life than a well fed wraith. And for Diet Dependent undead, this clause only takes effect at a point at which they also lose the ability to move, creating a similar issue to drug withdrawal rules.

So, here’s my suggestions for how to go about representing an eroding will to not do multi-step activities your character feels compelled to do.

First, one option would be to do a Wisdom saving throw for each step, increasing the DC progressively with each failed save. For example, the alcoholic in withdrawal might have to do a Wisdom saving throw to determine whether they walk home past the bar, or choose a different route to avoid passing the bar. On a failure, they walk towards the bar, and then when they are about to pass it, they must make another Wisdom saving throw or enter the bar. They then proceed to make another Wisdom save or order a drink, and another Wisdom saving throw or drink it. Then they make another Wisdom save vs ordering a second drink, and so forth. This continues until they’ve either made it back out of the tempting situation, or drunk themselves to unconsciousness, or if something causes another urge to be stronger than the urge to drink (eg, if the bar catches fire, the urge to avoid burning to death will supersede the urge to keep drinking).

For a vampire, a similar sequence might look like first going to a popular place to meet a one-night stand, choosing a target, flirting with the chosen target, charming the target, getting the target alone and biting the target. Or whatever hunting strategy would most fit with that vampire’s character and/or prior history. Unlike the alcoholic ordering a drink, the vampire luring a one-night stand to bite has a potential to fail despite the vampire’s best efforts (e.g. if the target succeeds a save vs vampire Charm, or the vampire fails a Persuasion check along the way). In that case, the failure could elicit another Wisdom save vs the urge to try again (possibly on a different target).

Another option would be to represent the character’s will to not do the thing they want to do as a set of arguments against doing it. For example, the alcoholic might have a list like:

  • I’m risking liver damage
  • My ex-wife won’t let me see my kids if I can’t stay sober
  • I got fired from my last job for showing up drunk, and I want to keep my current job
  • I’d like to have money to spend on things other than booze
  • Getting drunk makes it easier for the assassins hunting me to potentially kill me

Then the PC ranks each of those reasons from most to least important for this character. When they feel a craving, they must make a Wisdom saving throw, and on a failure, they negate one of those reasons. For example, the alcoholic might decide that the other things they could spend their money on aren’t as worthwhile to them as getting drunk, or that they don’t really care about their liver’s health, or that their ex-wife will probably find some other reason to keep them from seeing their kids. This counterargument doesn’t have to be, and probably shouldn’t be, something a rational person would consider a good argument, but it’s one that feels compelling to that character, and pushes them closer to being willing to drink alcohol.
With either option, if the character satisfies their craving, they could revert to their initial state of being totally unwilling to satisfy their craving ever again, along with feeling really unhappy about their recent actions. Conversely, you could combine the two options by having them make saves against action sequences during a craving, and then upon satisfying the craving, make a save against losing a reason to not indulge the craving in the future. Each lost reason makes the DC against the first step of the action sequence harder in the future.
And now, how I put this in practice!
This takes place in our Westmarch-style D&D campaign where adventurers spend their downtime in a Planar City created by a silver dragon archmage. One of my PCs, Xalith Baenduis, is a drow who has been partially ceremorphosized, or turned into an illithid. (She's an aberrant mind sorcerer.) She's not illithid enough to actually need to eat brains, but she's illithid enough to feel a desire to eat brains, and due to a homebrew feat, she can also regain spent spell slots by eating brains. Meanwhile, I came up with the following list of reasons she doesn't want to eat brains (the numbers reflect the importance ranking):
  • It's gross. (#5)
  • I worry that acting more illithid-like will eventually make me lose my identity to the tadpole. (#1)
  • I'm friends with a githyanki who would be horrified by this behavior if she found out. (#2)
  • I might get kicked out of the Planar City if I'm seen as a threat to the other inhabitants. (#3)
  • The illithid might have an easier time finding me if they hear about brainless corpses being found. (#4)

Xalith and another PC of mine, a yuan-ti pureblood named Zsistla, were hanging out in Baldur's Gate, in a walled ghetto known as Little Calimshan, trying to deal with Zsistla being blackmailed into kidnapping a Calishite jewelry merchant to appease someone who caught her stealing a large sum of money from a merchant. Unfortunately, Xalith, as a drow, sticks out in Little Calimshan, and while they were trying to sneak around the neighborhood late at night, she got noticed by some thugs who decided to escort her out of Little Calimshan. She responded by trying to twin spell charm person, they both succeeded their saves, and a fight ensued.

Cut ahead several rounds. Xalith has successfully removed one opponent from combat using calm emotions, then ran around a corner and knocked the other opponent unconscious, but she knows reinforcements are coming. I considered fleeing with or without the unconscious goon. Without would be easier, but if she brought him with, she might be able to eat his brains. Cue a Wisdom save. I arbitrarily set the base DC to 12, and Xalith failed, so she proceeded to levitate while carrying the unconscious goon, hiding on a rooftop with him.

Next round, another Wisdom save failed, so Xalith takes out her dagger and tries to open his skull, but utterly fails. Rinse & repeat for another round. On the third round, with reinforcements getting closer, and her not very well hidden (I rolled badly on nearly every Stealth check Xalith made that whole session), she finally succeeds the Wisdom save and abruptly decides that no, she does not in fact want to eat this guy's brains, she wants to GTFO now.

She regroups with Zsistla, and we try and utterly fail to kidnap their target, and then decide to go hide somewhere and rest for 4 hours (long enough for a short rest for Zsistla and a long rest for Xalith, since we've interpreted the trance racial feature as allowing 4 hour long rests). Unfortunately, we come out of our hiding spot to find we're surrounded by goons, led by Rilsa Rael, an NPC the DM took from the Murder at Baldur's Gate premade adventure. There's far too many for us to fight, so when Rilsa Rael decides to start asking questions, Zsistla spills the beans.

Turns out Rilsa Rael is willing to team up with us to double-cross Zsistla's blackmailer, so we happily agree - we were intending a double-cross anyway, and allies make that double-cross much safer. Part of the agreement is that we should lead Rilsa to where we stashed their missing goon. Miraculously, it turns out that he survived, and Xalith silently feels deeply relieved that she didn't have to try to explain (to both Zsistla and Rilsa) why the guy's head was cracked open and his brains eaten. The rest of the session goes smoothly, and we finish off with a blackmailer defeated, some information for Zsistla about his connections and motivation, and Rilsa as a friendly contact willing to give us a favor sometime because we helped her deal a serious blow to a rival gang the guy was affiliated with.

Xalith hasn't actually eaten a brain yet, so I didn't have a chance to see if she decided brain-eating isn't actually gross at all. But I've seen benefits to both parts of the system, now.

As a character-building exercise, figuring out all the reasons why Xalith doesn't want to eat brains gave me a much clearer sense of her personality. Note, for example, that moral objections aren't on the list, because she's chaotic evil. But the fact that fear of becoming more illithid is number 1 has clarified for me that in general, Xalith is deeply afraid of losing what shreds of her identity she's managed to hold onto so far. The fact that her memories of her previous life are full of gaps, her trance now involves visions of eldritch vistas with a giant elder brain (Ilsensine), and her instincts are different now worries her, and the thought of changing even further absolutely terrifies her. This tells me a lot of stuff that's useful to understanding her even when she's not craving humanoid brains.

And in actual play, figuring out component steps and rolling a Wisdom save for each one really helped me create a scene where she almost succumbs to the urge and then catches herself. In that situation, the steps I had in mind were a) bring the goon somewhere private, b) open up his skull, and c) eat his brain. So, she could have succeeded in shaking off the urge at any of those steps, and since she failed step b) several times, she got several tries at it. If I had actually rolled better than a 5 on my dagger attacks with advantage, though, I could have gotten his skull open. At which point, would she have actually eaten his brain? I'll never know. I know I loved the uncertainty of not actually knowing if she'd be able to stop herself from eating his brains, and I loved how the failed saves, failed attacks and finally successful save created a story of almost succumbing to temptation that I probably wouldn't have been able to come up with on the fly by myself.

I did forget about my intention to increase the DC with each failure for a point of no return, but it didn't actually matter, because my successful save was well above the cutoff.

Tuesday, March 15, 2022

Rejection Sensitivity, ADHD, and Quackery

To hear people talk about it, rejection sensitive dysphoria, also known as rejection sensitivity, is unique to ADHD. I even saw toxic people on Tumblr accusing non-ADHD people who described their experiences with rejection sensitive dysphoria as "culturally appropriating" (even though ADHD isn't a culture, it's a neurotype, and neurotypes are inherently arbitrary categorizations). And on a Google search for rejection sensitive dysphoria, the first six results discuss it in association with ADHD, with only the sixth result mentioning any other diagnosis that could be associated with RSD. Google also reveals the person who seems to be responsible for the belief that RSD is unique to ADHD - William Dodson.

But what does the research literature say? Is rejection sensitivity unique to ADHD?

This is actually two questions in one. First, are people with ADHD more likely to experience intense negative emotions from rejection, and secondly, are intense reactions to rejection common in any other clinical group?

ADHD and Rejection Sensitivity

Canu & Carlson (2007) studied NT, ADHD-C and ADHD-IA men in undergraduate university, and did not find significant differences in rejection sensitivity, assessed via self-report questionnaire, between the three groups.

Motamedi et al (2016) studied kindergarteners who either met criteria for ADHD, showed subthreshold ADHD tendencies, or were neurotypical, and assessed “rejection reactivity” by having the children customize an abstract shape as an avatar and then watch their avatar play with another shape, and then get abandoned for a third shape. Afterwards, they were asked how the video made them feel and how intense their feeling was, and those who said they felt “a lot” of a negative emotion were classified as rejection reactive. Hyperactivity, but not inattentiveness, was correlated with rejection reactivity.

Apart from these two studies, I wasn’t able to find any other publicly-accessible studies of rejection sensitivity in ADHD. Overall, it seems like there’s mixed evidence regarding whether or not rejection sensitivity is associated with ADHD.

Rejection Sensitivity in Other Clinical Groups

Unsurprisingly to anyone who knows anything about borderline personality disorder, rejection sensitivity is clearly correlated with this condition. I found many studies of BPD and rejection sensitivity, three of which are described below.

Ayduk et al (2008) studied the correlation between borderline personality features, rejection sensitivity, and executive control in several general population samples, and found that the combination of low executive control and high rejection sensitivity predicted higher borderline personality features.

Meyer et al (2005) studied borderline personality features and their association with rejection sensitivity measured both by a questionnaire and reactions to a vignette of an ambiguous social situation that could be interpreted as involving rejection, in a heterogenous general community sample. Borderline features were associated with rejection sensitivity as measured by both the questionnaire and the vignette.

Barros (2016) assessed borderline personality features and rejection sensitivity in staff and students at a university, and found a significant correlation between the two, indicating that individuals with more borderline personality features were more sensitive to rejection.

Depression is also, unsurprisingly, associated with rejection sensitivity. Here’s several studies:

Waller (2015) studied 11-17 year olds with major depressive disorder compared to mentally healthy controls, and found that self-report rejection sensitivity was significantly higher in depressed teens.

Bondü et al (2017) studied 9-21 year olds in a 1-2 year longitudinal study of several dimensions, including depression and two types of rejection sensitivity - anxious and angry (divided by what negative emotion rejection elicited). Participants with higher depression symptomatology were higher in both types of rejection sensitivity at both times. However, the association between time 1 rejection sensitivity and time 2 depression (controlling for time 1 depression) differed by type - anxious rejection sensitivity was associated with increases in depression over time, whereas angry rejection sensitivity was associated with decreases in depression. Meanwhile, time 1 depression was associated with increases in both types of rejection sensitivity by time 2.

Ng & Johnson (2013) compared adults with bipolar I who were currently in remission to mentally healthy individuals, and found that the bipolar participants had higher rejection sensitivity. However, when current depression symptoms were controlled for, this difference disappeared. On 6 month follow-up, rejection sensitivity predicted increases in depression symptoms but not mania symptoms.

There’s also some other diagnoses that came up in a few studies.

In addition to borderline features as mentioned above, Meyer et al (2005) also studied avoidant personality features and their association with rejection sensitivity measured both by a questionnaire and reactions to a vignette of an ambiguous social situation. Avoidant personality features were very strongly correlated with rejection sensitivity in the vignette, and less strongly but still significantly correlated with rejection sensitivity using the questionnaire measure.

Keenan et al (2018) studied autistic traits and rejection sensitivity in university undergraduates, and found that the two were positively correlated, indicating that individuals with more autistic traits were more sensitive to rejection.

In conclusion, rejection sensitivity is definitely not exclusive to ADHD, and it’s unclear if it’s even associated with ADHD at all. Rejection sensitivity appears to be primarily associated with depressed mood states and with borderline personality disorder, and possibly seen in other conditions such as autism and avoidant personality disorder.

So why do people think it is?

In my impression, there’s a lot of quackery in the ADHD world, and it seems to have a unique flavor. ADHD symptoms can be associated with a variety of underlying causes, and sometimes it’s more accurate to describe a person’s ADHD symptoms as simply manifestations of another condition, rather than as true ADHD. However, it seems like ADHD “specialists” rarely consider any differential diagnosis for ADHD, and instead treat variation in symptomatology in ADHD as different types of ADHD.

A good example is the book Healing ADD: The Breakthrough Program that Allows You to See and Heal the 7 Types of ADD by Daniel Amen. If you look through Amen’s seven “types of ADD”, defined by fMRI and symptoms, a lot of them sound suspiciously like other conditions that should be considered in differential diagnosis. “Ring of Fire” ADD is defined by an fMRI pattern that is highly distinctive and unique to an acute manic episode, not ADHD/ADD, and the symptoms described seem more fitting with mania, as well. Meanwhile, overfocused ADD sounds like obsessive-compulsive disorder or an anxiety disorder, temporal lobe and limbic ADD sound more like different flavors of depressive disorders, and anxious ADD sounds like - you guessed it - anxiety disorders. Whether or not these cases actually do have ADHD in addition to these other conditions is unclear, but in any case, symptoms of other conditions in a person with an ADHD diagnosis should be addressed and assessed directly, not treated as just “subtypes of ADD”.

I think William Dodson is cut from similar cloth as Daniel Amen - another ADHD “specialist” who forgets that ADHD isn’t the only possible explanation for his patients’ symptoms, and neglects to look for any other psychiatric conditions that might explain the symptoms he’s observing.

Of course, ADHD isn’t the only neurodivergence that’s riddled with quacks. Autism has plenty of quacks, too, although their tactics are generally different. The biggest difference I’ve noticed is that autism quacks tend to be liked by NT parents of autistic kids and absolutely detested by actual autistic people, whereas ADHD quacks seem to be able to get the respect of their actual patients and not just their patients’ parents. This means that the social justice heuristic of “nothing about us without us” is far less effective at weeding out quackery in ADHD than in autism.

However, autistics should take this as a caution. I’ve seen more and more autism “experts” who are paying lip service to listening to autistic voices, meanwhile still peddling misinformation that could be harmful to autistic people. As we gain more power and influence, the quacks could start to pay more and more attention to marketing directly to us instead of just to our families.

Monday, February 14, 2022

Community for Me or my Baby, Not Both

The February Carnival of Aros topic is on Community.

I've debated with myself quite a bit about whether or not to enter it, mainly because I feel like I don't really have a safe community, and pointing that out and explaining why feels unsafe. But I've decided that I need to say my piece anyway.

I've always been pro-life. It's never really made sense to me why this is an unusual stance among leftists, because to me, my pro-life stance follows from the same basic principles that make me anti-classist, pro-LGBTQ+, feminist, and all those other standard leftist ideals.

Essentially, I believe that human beings have inherent value, and should not be harmed unnecessarily. I believe that when the convenience of someone with greater power is weighed against the basic needs of someone with lesser power, to choose to prioritize the convenience of the one with more power is abominable.

I've heard leftists pro-choice people talk about how hypocritical the pro-life right-wingers are. I've also heard pro-life right-wingers talk about how hypocritical pro-choice leftists are. I honestly think both groups are equally hypocritical, and equally happy to call out hypocrisy in others while ignoring their own. Both groups are deeply inconsistent about whether they think personal autonomy or not harming others is more important.

For a long time, I ignored this issue. I didn't mention that I was pro-life, and hung out with pro-choice people who didn't mention they were pro-choice, meanwhile pretending to myself that they had to be pro-life because they talked about the same core principles that I support.

But then I started trying to conceive, right around the same time I noticed a bunch of pro-choice leftists deciding that they were sick of being silent about abortion. And now I'm pregnant, and acutely aware that there is most definitely a distinct and individual person inside me. (The most confusing pro-choice people to me are people who have ever participated in a prenatal ultrasound and remained pro-choice. It seems inconceivable to me that you can look at a wiggling, kicking little human reacting to stuff happening around them in real-time and still think they're not human enough to have a right to life. But then again, I've never been good at understanding dehumanization.)

And at the same time, I'm a queer aroace single nonbinary parent-to-be, who has refused to find out my baby's sex while also buying lots of gendered baby clothes I plan to dress them in regardless, and who used assisted reproduction to get pregnant without ever having had sex, and has contemplated looking into transition resources if I can ever get my complicated gender feelings sorted out enough to know what I actually want.

So who can I talk to about the enormous changes happening in my life? Not the people who would deny my humanity and tell me that I'm selfish for not finding some man to "be the father" and want me to pretend that what lies between my baby's legs is the most important determinant of their personality. But also not the people who talk about how it should be totally acceptable to kill people very much like the person I'm nurturing and devoted to caring for, who want me to sit there feeling excited little kicks and pretend their source isn't a living human who deserves protection and support regardless of how I personally feel about them. I don't want to have to choose between people who see me as a person but not my child, and people who see my child as a person but not me.

So, I don't really have a community. All I see is hypocrites all around, and a few solitary sensible voices caught in the middle and afraid to speak up.

Tuesday, February 08, 2022

Autistic Weaknesses or ABA?

I've noticed an interesting pattern. A lot of commonly-stated weaknesses of autistic children are traits that can be caused by too much ABA.

Black and White Thinking & Lack of Creativity

In ABA, an answer is either correct or incorrect. If it's correct, it will be rewarded. If not, it won't be rewarded - it may even be punished. ABA has no procedures for if the therapist doesn't know the answer, or for correct answers the therapist didn't think of, or answers that could be argued to be both correct and incorrect. If they're asking the question in a discrete trial, they have a correct answer in mind, and any other answer is wrong.

Creativity requires a more open-ended perspective, where an infinite number of potential answers are equally acceptable. If drawing flowers means drawing the particular flowers your teacher has in mind, then how can you learn to paint flowers with all the colors of the rainbow?

Difficulty Generalizing

Overall, a discrete trial tends to be extremely precise, with each presentation involving, as much as possible, exactly the same command in the same wording with the same intonation. When your experiences of learning a skill are so uniform, how are you to know which cues are or aren't important to determine when you should make use of the skill?

In tests of effectiveness of ABA, it's common to do reversal tests, confusingly also known as ABA or ABAB. The point is that when you remove the cue designed to elicit the behaviour change, behaviour reverses to baseline.

Ironically, this exact same response that is often taken as proof of effectiveness of ABA procedures is also frequently framed as a problem - failure to generalize. Even with the exact same contingency, reversal of behaviour change in response to minor environmental changes can be seen as a good thing at one point and a bad thing at another point. It makes little sense to me, reading papers written by and for ABA practitioners. How much less sense must it make to a child being taught by these methods?

Reversal tests not only prove that generalization has failed, they also promote more failure to generalize, by training the child with experiences that prove the contingency they’re learning is situation-specific.

When ABA therapists want a child to generalize a behavior, their usual strategy is to recruit more people in the child’s life to reinforce the desired behavior. This can be a difficult prospect, since even one person who doesn’t consistently enforce the desired contingency will teach the child that there are situations this behavior doesn’t get that reward in. But even if it works for everyone, it simply kicks the problem further down. If the person ever graduates from the ABA program, if they ever achieve independence, they’ll be in a situation where they’re no longer expecting rewards for the trained behavior.

True generalization tends to come from understanding the reasons why a behavior is useful and learning to independently identify when the behavior should be applied. This is not taught by ABA. A child learns to say “blue” not by learning that saying “blue” directs their communication partner’s attention to blue objects and therefore makes it easier for them to understand that a communicated message pertains to a blue object as opposed to the red one beside it - no, they learn that if the therapist shows them a blue object and says “what color?” and they say “blue”, they get an M&M (of any color!). If the person doesn’t ask them what color something is, uses an actual sentence (“what color would you say this ball is?”) rather than a sentence fragment, or isn’t holding a pack of M&Ms, will saying blue be useful? They don’t know.

In fact, verbal behavior theory fails to account for the main goal of communication. If you say “milk please” and actually use that as a communicative phrase, even though you might like to get an M&M, getting an M&M isn’t the goal - getting milk is. Verbal behavior theory treats all rewards for verbal utterances as equal. However, only responses that are actually connected to the message encourage the child to make the connection that the word “milk” and the word “please” actually have meanings and can be used to communicate their thoughts to others.

Sometimes, children receiving ABA will incidentally learn that the skills they’re being taught in ABA actually have a use. A child will sit on a potty and pee to get an M&M, only to incidentally learn that this behavior also keeps them from having to put up with the discomfort of a wet diaper. A child will happen to echo a trained phrase in an untrained situation and get a response that actually reflects the meaning of the phrase. But these things happen by accident, not intention, in ABA. And they don’t always happen for every skill that’s taught in ABA.

Aggression & Self-Harm

Martin Luther famously characterised violent protest as “the language of the unheard”. In children, aggressive behavior is usually attributable to emotional distress, instinctive threat responses, and the communication function of refusal. Self-harm, meanwhile, tends to be more specifically linked to distress.

ABA programs focused on developing communicative behavior tend to overlook refusal. Picture Exchange Communication System, an AAC intervention pioneered by ABA specialists, teaches requesting first, followed by commenting, and never even mentions refusal, not even in the “next steps” once the child has completed training.

This is not an accidental oversight. Many children don’t enjoy prolonged ABA instruction, and if adults were to honor their refusal communications, they would receive far fewer discrete trials. In addition, many goals of ABA involve teaching the child to accept stimuli they’d normally refuse, such as eye contact and physical touch, and that requires deliberately and consistently ignoring refusal communications.

Emotional distress is unacknowledged in most ABA programs. ABA comes from behaviorist theory, a theoretical approach that attempts to explain behavior solely through external factors. Emotional distress is an internal experience, outside the scope of behaviorist theory. The closest that behaviorist theory comes to acknowledging emotional distress is in acknowledging that organisms enjoy certain things more than they enjoy other things - however, this completely ignores the way that overwhelming emotional distress can result in irrational and counterproductive behavior that is beyond the individual’s conscious control. It’s quite common for individuals to engage in behavior that is consistently punished when they’re experiencing emotional distress, because their distress demands action and they don’t know any way to relieve or tolerate distress that won’t get them punished.

Autistic individuals can experience emotional distress for the same reasons as anyone else, but they can also experience distress for autism-specific reasons. For example, the majority of autistic individuals have some degree of sensory hypersensitivity, a neurological condition that causes distress at sensations most people aren’t bothered by. These can include sensations associated with the intended goals of ABA treatment, such as seeing people’s eyes or being touched, as well as incidental sensations such as background noises, fluorescent lighting, etc.

Behaviors that lessen emotional distress are internally rewarding, even if they aren’t externally rewarded. If emotional distress outstrips an individual’s executive functioning, they will compulsively engage in the most powerful emotion distress-reducing behaviors they can think of, regardless of any external consequences. At this point, punishment tends to merely increase the person’s distress, resulting in an increase rather than a decrease in the maladaptive behavior.

Punishment is ineffective at interrupting emotional distress behaviors not only because it increases distress, but also because the overall experience of being in distress is so innately punishing that a single act of external punishment tends not to stand out noticeably in comparison. What does stand out is anything that reduces distress, even momentarily.

Self-harm can lessen emotional distress by causing the release of natural endorphins. Endorphins are the neurotransmitters that opiate drugs mimic, and high levels of endorphins consequently result in similar sensations to taking a low dose of an opiate drug. In addition, physical pain attracts attention, reducing the person’s ability to focus on any other thoughts or feelings, including thoughts and feelings that are contributing to emotional distress.

Many parents of toddlers have noted that a momentary distraction can sometimes shake a child out of a tantrum, and pain is extremely distracting. Pain that is from an external source is both distracting and distressing, and therefore likely to only temporarily disrupt a distress response before amplifying it. However, pain that is under the control of the individual experiencing it is far less distressing, both because it’s predictable and because it can be tailored to be just the right level of pain rather than too much pain. (Although if a self-harming individual accidentally causes themselves more pain than intended, this tends not to function as desired.)

In addition, behaviorists have frequently struggled to predict or control instinctive behaviors - for example, raccoons trained by behaviorist methods to exchange tokens for food rewards eventually begin compulsively washing the tokens, impeding their ability to actually exchange the tokens for the food. Instincts tend to be more strongly controlled by classical conditioning than by operant conditioning, so stimuli associated with a situation that triggers instinctive behavior will trigger the instinct regardless of whether it’s a functional or even counterproductive response.

Humans, too, are animals, and we have instincts as well. One of our most powerful instinctive responses occurs in situations where we perceive ourselves (accurately or not) to be in imminent risk of serious or life-threatening harm - including many situations associated with extreme distress.

In these situations, we have three competing instinctive tendencies - fight, flight or freeze. If the fight instinct is triggered, the result is aggression. This is especially likely in situations where other tendencies are inhibited, especially flight - frequently, an attempt to escape a situation will turn into aggression targeted at whoever or whatever is impeding the individual’s escape. For example, a child in an instinctive threat response might first try to elope, and if restrained, respond with aggression towards whoever is restraining them. If this aggression fails, they may eventually become limp, and it may be difficult to elicit any response from them whatsoever. As long as the instinctive threat response state continues, if they do respond, it’ll be switching back into fight or flight mode. This is not a response subject to operant conditioning.

When ABA treatment elicits emotional distress and/or instinctive threat responses, the therapists are trained to respond in counterproductive ways, since more productive responses - ie doing things that reduce distress and communicate that the situation isn’t a threat - tends to be seen as rewarding the unpleasant behavior the individual is engaging in. For example, offering a comfort toy to a crying child is often an effective way to reduce distress, but it’s also giving the child something they find rewarding in response to a behavior you want to reduce. 

People who acknowledge internal experiences must learn to distinguish the difference between crying that is an uncontrollable response to distress and crying that represents an operantly-conditioned voluntary behavior, and provide responses that reduce distress but don’t reinforce operant conditioning responses. However, this balancing act only exists if you acknowledge that behaviorist theory doesn’t address the full complexity of human (or animal) behavior.

Furthermore, since most autistic people have atypical sensorimotor systems, they often have atypical self-soothing behaviors, such as rocking, monotone humming and hand-flapping. Unlike aggression and self-harm, these behaviors are essentially harmless, and therefore among the more adaptive means that many autistic people have to reduce their distress. However, since ABA for autism frequently has a goal of making the child look more superficially normal (often described as “social acceptability”), these atypical motor behaviors are often targeted for reduction regardless of any adaptive function they may serve.

While distress and instinctive threat responses don’t tend to respond well to operant conditioning, they tend to respond very strongly to classical conditioning. Classical conditioning is the kind of conditioning described by Ivan Pavlov, where an instinctive salivary response to food began to be elicited by a stimulus paired with food.

If you consistently respond to distress behaviors and instinctive threat responses in ways that increase the distress the person is experiencing, over time, classical conditioning will result in the internal experiences of distress and/or instinctive threat becoming more likely in situations that contain stimuli shared by the situation that has previously elicited distress and/or instinctive threat responses.

For example, a child who frequently experiences distress at school may come to find the sensation of wearing a backpack or the sight of a school bus also elicit distress. A child who enters an instinctive threat response state in the context of toilet training may eventually enter that state when they simply see a toilet. A child who, during an instinctive threat response state, was physically restrained to stop them eloping, fought back unsuccessfully and then fell into a freeze response may later exhibit any of those three responses to a momentary touch from the same person who restrained them before.

In severe cases, classical conditioning of instinctive threat responses can result in an individual developing mental health conditions that are characterised by overactive stress responses, such as specific phobias or even post-traumatic stress disorder. In children, instinctive threat responses and distress are also subject to neuroplasticity, with a host of permanent biochemical and behavioral consequences. For example, cortisol production appears to be elevated in many traumatised individuals, and yet permanently suppressed in the most severely traumatised children. Both elevated and suppressed cortisol likely have major implications for both behavior and physical health over the long-term.

The duration of ABA training and the frequently sedentary nature of discrete trial training are also relevant. Physical exercise reduces susceptibility to instinctive threat responses and is likely to release endorphins, just like self-harm does. Children generally are more inclined to be physically active than adults, a pattern seen across many vertebrate species as soon as they become capable of independent locomotion. This means not only that they are more likely to spontaneously engage in physical exercise, but also that they need more physical exercise to get the emotional benefits of exercising, and that they’re more susceptible to boredom and restlessness in the absence of physical activity.

ABA practice has, over time, placed less emphasis on doing discrete trial training with a child seated at a table, instead moving towards doing discrete trials on the floor surrounded by toys or in other contexts that feel more natural for a small child, the constraints of discrete trial training still generally require inactivity. If a child is running circles around the room, for example, they’re not looking at the block you’re touching when you say “what color?”

This enforced inactivity isn’t a huge concern if it occurs for brief periods, increasing gradually in duration as a child’s developmental need for physical activity decreases. However, ABA practice generally encourages intensive, early intervention, resulting in children as young as 18 months old being subjected to discrete trials for 30 to 40 hours a week. This is extremely developmentally inappropriate, since even 6 and 7 year olds are likely to struggle with being inactive for that much time during a week.

One way that children can attend to stationary activities and still meet some of their need for physical activity is by engaging in irrelevant small-motor movements - fidgeting. Since autistic children’s sensorimotor systems function differently from most children, these fidgeting movements, like the self-soothing movements described above, often look atypical in autistic children.

Unfortunately, despite fidgeting being essentially harmless and frequently enhancing the capacity to pay attention, it is sometimes distracting - to other learners, if present, and especially to the therapist or instructor who is actively monitoring the child’s responses. Furthermore, if fidgeting looks atypical, “social acceptability” goals can encourage a therapist to attempt to suppress this behavior even more so than normal fidgeting. Regardless of whether it looks typical or atypical, suppressing fidgeting increases the negative psychological consequences of prolonged, enforced inactivity.

In addition, not moving when you want to move is a form of behavioral inhibition, as is paying attention only to what someone else wants you to attend to. Inhibition is an effortful usage of executive control, and executive control is subject to fatigue. Executive control is also used to suppress maladaptive instinctive and/or emotional responses, and therefore, executive fatigue increases the risk that an individual will behave compulsively in response to their emotions and/or instincts.

Children not only need more executive control to inhibit movement since they have a greater drive to move - they also have less executive control overall, since the prefrontal, the brain region primarily responsible for executive control, is continuing to develop up until the mid-twenties. In addition, autism is associated with a generalized impairment in executive functioning, including impaired executive control - and if the individual has ADHD as well, a frequent comorbid condition, this is even more true.

A child with impaired executive control being required to inhibit activity during developmentally inappropriate prolonged sedentary activities requiring intense mental focus is extremely prone to executive fatigue. This is probably one of the big reasons that, despite the common recommendation that autistic children receive 30 to 40 hours a week of ABA treatment, better outcomes have actually been reported for children who receive less-frequent ABA treatment. Lower intensity treatment presents the child with learning opportunities with less risk of triggering executive fatigue.

This is the same reason why 4 and 5 year old typically developing children, if they are in formal preschool or kindergarten educational settings, frequently attend for half-days or every second weekday, resulting in much less time per week in formal educational settings than older children. Unfortunately, many people who recognize the increased need for downtime and physical activity in young typically developing children are nonetheless willing to require many hours of effortful control in same-age or even younger developmentally disabled children, despite the needs for downtime and activity being the same or greater in many of these children. Few people who support early intensive ABA for autistic toddlers would be comfortable with a daycare program that expects 18 month old typically developing children to sit still and focus on academic tasks for 30-40 hours a week. Is it surprising that a child subjected to such developmentally inappropriate instruction might experience escalating distress responses?