The Problematic Nature of Behavioural Treatments for Autism

Since Jim Sinclair's call for autism acceptance and accepting autistic individuals as they are in the early 1990s, his words are still not heard by many professionals, policymakers, and families. In contrast, Applied Behaviour Analysis (ABA) and its ‘modified’ and fancy-titled forms have become the most common autism interventions. These interventions are demanded by parents, funded by social and welfare systems, and uncritically supported by academia. Yet several autistic individuals, including activists and researchers, as well as autistic collectives, have highlighted the problematic nature of behavioural treatments.   

What is Behavioural Treatment?  

These interventions have a core principle: conditioning the individuals, that is, encouraging behaviours that are considered ‘desired (including encouraging the absence of ‘undesired’/‘challenging’ behaviour) and discouraging behaviours that are considered ‘undesired’ (including discouraging the absence of ‘desired’ behaviour). Encouraging and discouraging in this approach are based on a reward-punishment mentality: when a behaviour occurs, a consequence, that is, a reward or punishment, will follow. In some countries, ‘physical’ punishments and aversives have been replaced with deprivation or non-rewarding, and continuation of instructions until the individual follows instructions. The highly structured sessions in some contexts have changed to more child-led sessions. These sessions seem progressive as they indicate that some behaviourists have started to abandon problematic practices and rely on what they call ‘positive reinforcement’. However, this change has been made possible not because of behaviourists' ethical and scientific reflection, but because of the tireless work and activism of autistic advocates.

Even in highly problematic cases, such as at the Judge Rotenberg Centre (JRC), where neurodivergent individuals were tortured with Contingent Electric Skin Shock (CESS), the Association for Behaviour Analysis International (ABAI) avoided listening to concerns raised by autistic advocacy groups for years. Instead, and unsurprisingly, ABAI let the JRC sponsor its conferences, and their investigation task force on CESS failed to explicitly oppose the use of shock. It took years for ABAI to issue a statement opposing CESS. Furthermore, the problem with behaviourism goes beyond physical punishments or intensive, lengthy sessions, which can be up to forty hours per week for children as young as four. It is a fundamental issue with the practice.

Some of the Problems with Behavioural Treatments

Socially and Culturally Acceptable Behaviours are Neuro-normative, Arbitrary, Ableist, Capitalist, and Morbid

There is no clear definition of ‘challenging’ behaviours. However, ‘aggression, self-injury, and disruption to their environment, [… and behaviours] not culturally or socially acceptable, and/or negatively affect their life or education’ are typically included in the list. The distinction between ‘challenging’ behaviours and ‘appropriate’ behaviours is neuro-normative, arbitrary, ableist, and a symptom of a collective Empathy Deficit Disorder.

1. Neuro-normative  

Terms such as ‘challenging behaviour’ and ‘appropriate behaviour’ are defined based on a regime of truth and ideology, where autistic and neurodivergent experiences of the world are excluded and delegitimised. Stimming, a repetitive behaviour that usually does not pose a risk, is an illustrative example. Stimming can include repeating words, twirling hair, and tapping fingers or feet. Stimming is stigmatised and considered inappropriate by the neurotypical population; thus, behaviourism aims to remove or limit it. Let’s think beyond this neuro-normative approach that seeks to ‘fix’ a person according to neurotypical norms. When you consider the experiential knowledge of autistic individuals, you’ll find that stimming has communicative and regulative functions. Stimming helps autistic people express their feelings and overcome overwhelming environments and sensory overload.  

2. Arbitrary  

It is unclear where the boundaries that distinguish socially and culturally acceptable and unacceptable behaviour lie. This isn’t to say that reality is relative, but to highlight that social and cultural norms and acceptability of behaviours are contextual, gendered, racialised, and have historically and politically constructed aspects. Let's consider the pathologisation of stimming. Many people stim when they are stressed, as a form of communication or relaxation, or even for no reason, yet such behaviours are not pathologised in neurotypical people.  

3. Ableist

Social and spatial causes and drivers of the behaviours labelled ‘challenging’, are often neglected. For example, autistic individuals experience meltdowns due to overwhelming environments. However, from the behaviourist perspective, meltdowns are not only considered ‘tantrums’, but there’s also no need to address social and spatial barriers or factors causing meltdowns.

The behaviours labelled ‘challenging’, caused by social and spatial factors and barriers, are often neglected. For example, autistic individuals experience meltdowns due to overwhelming environments. However, from the behaviourist perspective, meltdowns are not only considered ‘tantrums’, but there’s also no need to address social and spatial barriers.

4. Behaviourists' Collective Empathy Deficit Disorder

There is an irony in the pathologisation of autism and the neglect of autistic individuals' perspectives and needs. Autistic individuals are usually considered to have limited empathy. The American Psychological Association defines empathy as ‘understanding a person from their frame of reference rather than one's own’. Based on this definition, many behaviourists are showing symptoms of Empathy Deficit Disorder in their professional practices. They fail to understand autistic experiences and the drivers and functions of behaviours from an autistic frame of reference. This becomes apparent when we consider that following some instructions, like making eye contact, may cause distress for autistic people. However, behaviourists make them make eye contact anyway.

5. Capitalist

Many autism rehabilitation practitioners contribute to the multi-billion-dollar industry of behaviourist treatments. Despite profiting from these treatments, many practitioners do not listen to perspectives from emerging critical autism studies and lack a fair level of reflection on their practices.

Second, the conditioning resembles an optimalist approach that attempts to reach a maximum outcome with the least possible use of resources. In behaviourism, the root causes of behaviours do not matter. What matters is finding the best consequence that will produce the desired response to an instruction.

Lastly, the obsession with ‘fixing’ autistic individuals to behave like neurotypicals is rooted in the belief of adjusting a human being to fit in the capitalist context of our time, where a responsible, independent, productive, atomised human being, a worker, is demanded.

Mental Health and Psychological Consequences of Behavioural Treatments  

Behaviourist treatments not only invalidate the autistic experience but also can cause emotional and psychological harm. Kupferstein finds that autistic individuals who have attended behaviourist treatment sessions are more likely to show PTSD symptoms. While further research might be required on this, if we consider that such a risk is probable, that is cause for concern. Furthermore, behaviourist treatments aim to reduce autistic traits. This contributes to social camouflaging or hiding autistic characteristics, a practice that we call masking in the autistic community. Masking contributes to mental health issues such as depression, suicidal thoughts and low self-esteem, according to studies informed by autistic lived experiences. 

Resource Exploitation  

Reliance on behaviourism is excessively consuming budgets, exploiting resources, and wasting opportunities. Many seats in universities within the rehabilitation and autism-related disciplines are allocated to train behaviourist practitioners. A considerable amount of welfare budgets for autism in many countries is consumed by financially supporting behaviourist treatment. In schools and support centres, several hours are allocated using behaviourist techniques. Above all, years of children's lives are used for these treatments. These resources and opportunities could be shifted to mobilise society, academia, and welfare systems for social change, as well as autistic-informed and autism-friendly services, research, and practices.

Concluding Thoughts

Behaviourism neglects autistic voices and experiences. The consequences can be psychologically harmful, distract from the socially and spatially hostile environment, and contribute to the pathologisation of autism. Behaviourism exploits resources that could be used for autistic-informed and autism-friendly services. If we are truly concerned with the fight for a more equitable and just world, wherever we are, from academia to practice, then we must critically counter behaviourism. We can do this by promoting epistemological justice, policies, and practices informed and led by autistic individuals.  

The views expressed in this post are those of the author and do not necessarily reflect the position of the Atlantic Fellows for Social and Economic Equity programme, the International Inequalities Institute, or the London School of Economics and Political Science.