Introduction

Michael Fitzpatrick is a retired GP with a profoundly autistic son. Mike is also the author of MMR and Autism: What Parents Need to Know and Defeating Autism: A Damaging Delusion. He usually writes for Spiked Online. But he has asked me to host his review of a recent BBC4 documentary, Autism: Challenging Behaviour. The programme claimed to be a

Documentary exploring the controversy around ABA (Applied Behaviour Analysis), an intensive intervention used to treat autism, by meeting people who are both pro- and anti-ABA.

Applied Behavioural Analysis is a system of instruction devised by Ivor Lovaas that  is based on B. F. Skinner’s theory of operant conditioning. Its supporters are wont to claim that it is “the only scientifically proven therapy for autism.” Here is a typical offering from Families for Early Autistic Treatment (FEAT) in British Colombia, who are part of a campaign to have ABA mandated as a necessary medical treatment for autism in Canada.

Effective, scientifically backed treatment for autism exists (the “Lovaas” Method – a form of Applied Behavior Analysis). Lovaas behavioural treatment for autism is medically necessary and prescribed by physicians because it is the only treatment available that significantly improves this biological disorder. Lovaas behavioral treatment for autism is the most thoroughly documented treatment of children with autism. Scientific studies document a 47% recovery rate from autism and a near 100% improvement rate for children who receive Lovaas early treatment.

In the United States there is a campaign to compel health insurance companies to include ABA as a medical intervention for autism, ABAmaCare if you like. These campaigns are not without controversy. Michelle Dawson, an autistic individual and autism researcher in Canada is perhaps the most eloquent advocate who challenges the scientific and ethical foundations of ABA. She is not alone. But the BBC4 documentary made no reference to Michelle’s critique of ABA.  It followed the more familiar route of human interest documentaries. The case for ABA was made using heart warming individual success stories, balanced by critical remarks from autism experts who questioned its scientific and ethical credentials. No prizes for guessing who won. So thank you Michael Fitzpatrick for eschewing emotional appeal and providing us with this critical review of the documentary.

Autism: Challenging Behaviour

Producer/Director: Fran Robertson

BBC4, 5 November 2013

Fran Robertson’s documentary tells the story of two engaging little boys with autism – Jack aged three, and Jeremiah, four – who attend Treetops school in Thurrock, Essex, the only state school in the country in which the curriculum is based on the intensive behavioural techniques of Applied Behaviour Analysis (ABA). Blonde with an angelic smile, Jack responds with tantrums and projectile vomiting to any food beyond a highly restricted liquid diet. Dark-haired and bright-eyed Jeremiah seems to inhabit a ‘world of his own’ from which his Indian parents struggle to engage him. In the course of the film we follow the attempts of teachers and teaching assistants to overcome these boys’ behavioural and communication difficulties through the techniques of ABA.

The film explores the long-running controversy around ABA through interviews with academic critics and adults who have been diagnosed with autistic spectrum disorders, including one mother who was diagnosed with Asperger’s syndrome following her son’s diagnosis. Early forms of ABA, which emerged from the pioneering work of the Norwegian psychologist Ivar Lovaas in California in the 1960s, were condemned for using punitive ‘aversive’ techniques. Though these have long been abandoned, critics still claim that ABA is dehumanising, seeking to ‘normalise’ autistic behaviours – such as repetitive, self-stimulatory, activities – which are functional for people with autism.

Another area of controversy around ABA – the question ‘does it work?’ – is avoided in this documentary, which tends to take at face value the assertion by campaigners, teachers and parents committed to this approach that it is effective. Much research, summarised in two recent systematic reviews, has failed to provide categorical endorsement. Studies show that while some children with autism benefit from ABA, some do not; some benefit more than others; and some children make progress without intensive behavioural intervention (and to a degree comparable with those who receive it). The problem is that we still do not know how to identify which children are most likely to benefit from ABA and which from other forms of intervention, or what particular aspects of the ABA approach are likely to benefit particular children.

At the end of Autism: Challenging Behaviour, we see Jack cheerfully tucking in to sausage, beans and chips with his mother and Jeremiah playing happily with his parents. But this emotionally manipulative presentation of ABA takes little account of the experience of many parents – that of limited progress despite immense efforts and of disappointment at their failure to achieve the promised outcomes.

The uncritical advocacy of ABA goes even further in a number of episodes featuring the Scandinavian therapist Gunnar Frederickson, who follows in the dubious tradition of campaigners who claim that ABA can achieve “cure” or “recovery” from autism. As British autism expert Rita Jordan has observed ‘the whole ABA movement appears increasingly more like a cult than a science’. Charismatic, dogmatic and sanctimonious – and with a passing resemblance to the rock’n’ roll philanthropist and activist Bono – Frederickson takes the film crew to the scene of his greatest triumph over autism. We meet a 16 year old boy, treated by Frederickson at the age of three when his parents were told he was ‘unlikely to speak’. He is now ‘indistinguishable from his peers’ and a member of the Swedish badminton team. He lives with his happy family in a beautiful, spacious, white house (in stark contrast to the dark, cramped and impoverished conditions in which we see some of the British children with autism are living). While any sceptical observer would want to know more about both the original diagnosis and the current level of functioning, it is the wonder cure that makes good television – and guarantees continuing demand for ABA, despite the lack of scientific evidence for its efficacy.

It is important to note that some proponents of ABA – such as Professor Richard Hastings – repudiate both the ‘normalising’ and the ‘cure’ agenda: ‘just because some individuals or organizations argue that ABA can lead to some sort of recovery from autism does not mean that this is what ABA is all about.’

Michael Fitzpatrick 6 November 2013

Further reading:

Howlin P., Magiati I., Charman T.(2009). Systematic review of early intensive behavioral interventions for children with autism. American Journal on Intellectual and Developmental Disabilities. 114(1), pp. 23-41.

Spreckley M., Boyd R.(2009). Efficacy of applied behavioral intervention in preschool children with autism for improving cognitive, language, and adaptive behavior: A systematic review and meta-analysis. Journal of Pediatrics. 154(3), pp. 338-344.

Prof Hastings blog: http://profhastings.blogspot.co.uk/

Michael Fitzpatrick, ‘The Lovaas cure: ABA is it a fad?’ in Defeating Autism: A Damaging Delusion, Routledge, 2009, p138-141.