In a 1958 psychology textbook, a chapter on childhood schizophrenia started this way:
Partisan points of view have no place here. The field is too young; all of us are still groping in the dark. The more objectively the worker can approach open questions, and study the partial answers to others, the better equipped he will be to contribute toward the solution.
Childhood schizophrenia was then used as an interchangeable term with autism. These authors’ contemporaries were mostly coming to the conclusion that the children with autism in their care were the victims of damagingly bad parenting, which could be corrected with psychotherapy for both parent and child. This theory of the cause and treatment of autism failed and many more ideas that were unsupported by evidence have failed in its wake.
Fifty years later, the field is not so young, but those fifty years would have been better spent if the advice of those authors had been followed. Rather than acting on theories and assumptions, practitioners could have considered a very important piece of knowledge – knowing what you don’t know. We still don’t know the answers to many fundamental questions about autism. Findings in genetics and other disciplines are suggesting that individuals with autism are more heterogeneous and variable than anyone fifty years ago would have imagined. However, when working today with children with autism we can re-learn this old lesson.
Consider what an educator knows about a child when they come into the classroom or clinic. Often, all the information is that they have a diagnosis of autism. The diagnosis may call to mind a lot one has learned from other individuals, or from books, conferences and classes. But what do you know about the specific individual in front of you?
You know only three things: They have a deficit in communication. They have a deficit in socialization. They exhibit repetitive or stereotyped behaviors. You may have documentation detailing these three domains of the child’s functioning, or you may not. Even if you do, how much do you know?
Apply these three domains to yourself and see how revealing they are. In my case, I perform somewhat above average in the communication domain. I work as a writer of government publications. Before that I was a college English teacher. In the social domain, I’m about average. I can hold up my end of most conversations, but I’m awkward at parties. I don’t have any repetitive behaviors outside social norms, though I fidget with my pen in meetings and often whistle tunelessly to myself.
Knowing that much, do you know anything that is useful to an educator or therapist? Do you know what motivates me? Do you know how I learned any of the skills I have or have any insight to how I might learn more? Do you know if I’m bothered by any particular sensations? Do you have any indication of my IQ? (Consider the range between the brightest professor and the daftest bureaucrat you’ve ever met). So what’s the protocol for ‘people like me’?
The heterogeneity of any group of people defined by their functioning in these three domains is vast. So is the heterogeneity among children with autism. So when a child comes into a new learning environment, a teacher should consider what may be the most important thing they know – you know that you don’t know.
The first step, then, is to gather information that will fill the gaps. This step is what makes applied behavior analysis (ABA) so well suited to teaching children with autism. All ABA begins with a careful study of the individual child, seeking to have the child teach the teacher how the child learns.
First, a teacher begins with a careful reinforcer survey so they can determine what motivates the child. Using those reinforcers to test performance during skill assessments, that teacher gathers direct data about what the child knows and needs to know. By exposing the child to different environments and again gathering data on how the child responds, the teacher learns the settings that are conducive to that child’s learning.
Using the data from the most authoritative source, the child, the ABA teacher forms a hypothesis about how to most effectively teach them. The hypothesis will lead to choosing strategies from various ABA methods that have been validated in research studies – discrete trial training, milieu teaching, pivotal response training, etc. While proven to be effective with research subjects, these procedures aren’t chosen because “they work for kids with autism.” They are chosen because the study of one child gives reasons they may work with that child.
Once any procedure is implemented, the ABA teacher doesn’t continue on the assumption that the procedure is correct. They don’t know that yet. They’ll know it only when the child learns. If, after repeated trials, data shows the child isn’t learning, the process begins again – learn more about the child, change procedures, test the results again.
This is a model of evidence-based practice. In the seminal essay on evidence-based practice, Sackett et al say it “means integrating individual clinical expertise with the best available external clinical evidence from systematic research.” The ABA teacher only knows things about a child that they have learned from direct clinical experience with that child. They only apply procedures which are research-based. Otherwise, they remember what they don’t know. While we wait for answers to the more fundamental questions about autism, this kind of evidence-based practice is arguably the best strategy to address the heterogeneous needs of autistic children.
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