6.5 Treating behavioural symptoms
The Lovaas approach focuses specifically on changing ‘autistic’ behaviour (rocking, obsession with objects, idiosyncratic speech or no speech). The approach, elaborated and practised by Lovaas and colleagues for more than thirty years, rejects the notion of explaining autism in terms of underlying or core problems – whether these are at the socio-cognitive or biological level. It has its roots in the behaviourist tradition; its key assumptions are described in Box 13.
Box 13: The Lovaas Approach
Key assumptions are:
Autism is characterised by behaviours that are detrimental or destructive to the child and/or to those around him or her.
The search for ‘underlying causes’ of autism may be theoretically misguided and is irrelevant to developing effective therapy.
Learning plays a central role in the autistic child's failure to acquire ‘desirable’ behaviours (such as physical contact with others), and in his/her acquisition of ‘undesirable’ behaviours (repetitive behaviours that may be injurious or antisocial, such as head banging, destruction of objects, taking clothes off in public, etc.). Therefore behaviour modification is an appropriate technique for changing these behaviours.
The key to behaviour modification therapy is to analyse the child's behaviour into ‘manageable’ components, that can be individually tackled.
An important extension of this approach (introduced in the 1980s) is training parents to carry out the therapy themselves at home.
In a typical application of these principles, the parent or therapist might decide to focus on a child's use of compulsive questioning. By consistently refusing to acknowledge or pay attention to these questions, the parent seeks to avoid providing reinforcement for them. However, if the child seeks the parent's attention without resorting to compulsive questioning, he or she is positively reinforced by receiving the therapist's attention. In this way, the therapist aims to ‘extinguish’ undesired behaviour, and increase and ‘shape’ desired behaviour.
Lovaas's approach has been reasonably effective in helping children with ASDs to control undesirable behaviours, especially those that are self-destructive, or anti-social to family members. It has also enabled impassive children to learn gestures such as smiling and waving, and previously mute children to acquire elementary language responses. Involving parents as the key providers of therapy obviates the need for therapy to be carried out in the unfamiliar environment of hospital or clinic, and this emphasis on home-based therapy has been emulated in many other therapeutic approaches.
Lovaas (1996) claimed that an intensive home-based programme during the pre-school years can ‘normalise’ functioning in about two-fifths of children with autism, and argued that these findings were inconsistent with neuropsychological models of autism. Note that in this instance the flow of ideas is from clinical practice to theory, rather than from theory to clinical practice.
Despite its benefits, criticisms of Lovaas's approach arise when we apply the criteria in Box 11:
Theoretical rationale: the approach is intentionally ‘atheoretical’ in addressing symptoms and rejecting the need to understand ‘causes’. However, the idea that autism is purely a problem of faulty learning is difficult to reconcile with substantial evidence for genetic and organic dysfunction, which in turn are linked to deficits in planning behaviour and in social understanding.
Methodological considerations: critics have argued that Lovaas's selection of participants is ill-defined, and that the design of the interventions cannot exclude improvements due to confounding factors. Lack of generalisation is a key problem: while children can be trained to make responses such as ‘Can I have a biscuit?’, this behaviour does not generalise into the command of syntax, semantics and pragmatics that is required to use language flexibly in different social situations. Similarly, though a child can be taught social responses such as smiling or waving, he/she may not have acquired an understanding of the subtle significance of these gestures in complex social interactions.
Ethics: Lovaas's approach requires a tremendous commitment of time (40 hours per week for the intensive programme) and emotional strength. These are likely to be beyond many parents' capabilities and may accentuate the kinds of family tensions mentioned in Section 4. Lovaas's approach also gives therapist and family the power to decide what behaviour is ‘undesirable’. This carries the danger of requiring a child to conform to his/her family's particular cultural stereotypes of what behaviour is socially acceptable, as opposed to helping the child to overcome behaviour that is actually damaging to self or others.
In its ‘pure’ form then, Lovaas's approach is controversial. However, elements of behaviour modification are included as a complementary feature of many educational and home-based therapy programmes. Some parents appear naturally gifted therapists: Tito's autobiography (Mukodpadyhay, 2000) describes subtle forms of behaviour modification that his mother intuitively combined with other strategies to help him to control problematic behaviour and develop his potential.