There are fundamental problems with the Board Certified Specialist in Autism Spectrum Disorders (BCS-ASD). Therefore, it is imperative that ASHA not only sever any relationship with the BCS-ASD, but vociferously work to prevent its adoption by speech-language pathologists.
Though exceptions exist, speech-language pathologists (SLPs) need a far greater understanding of autism than they currently receive in graduate school. The underlying research in support of the Certification as described is flawed, and the reputation of ASHA will be tainted if it remains silent on its position towards this Certification.
The problems are far deeper than the individual tasks that make up the Autism Specialty competency areas, or the list of the specific knowledges requirements of the the test domain that will make up the certification exam. These are described in the sections below as sections:
A. Fundamental Research Problems
B. Unanticipated Consequences on the Reputation of ASHA
A. Fundamental Research Problems
- Behaviorism is a fundamentally flawed theoretical foundation upon which the BCS-ASD lies.
At its core, “Behaviorism is a learning theory that only focuses on objectively observable behaviors and discounts any independent activities of the mind. Behavior theorists define learning as nothing more than the acquisition of new behavior based on environmental conditions.” (1)
The widespread acceptance of Skinner’s behaviorism (2) was in part a react(ion and rejection of Freud’s psychoanalytic theories of psychology. Whereas Freudian psychology required acceptance of psychological constructs (id, ego, superego), Skinner emphasized only observable behaviors, and the use of operant conditioning to train rats and pigeons. Ignoring or discounting the activities of the mind may have made sense in the 1940s, but in the first and especially second decade of the 21st Century we are finally beginning to understand how the brain works.
It is simply wrong to base a 21st Century certification of a neurological disorder on a theory that intentionally ignores the research in neurology.
Moreover, the foundation of modern behaviorism was Skinner’s work with rats and pigeons: In other words, the goal of operant conditioning was to “teach” an animal to do something it was not naturally inclined to do. An alternative way of thinking about operant conditioning is as a means of communicating with a different specie that does not understand human language. Dr. Doolittle, who could talk to the animals, would simply tell a rat that if it runs down a maze and turns left, it will find a piece of cheese. But Dr. Skinner could not talk to the animals, so he used operant conditioning to communicate to the rat to do the same thing.
Individuals with autism have human language skills. They are able to understand instructions. They do not need behavioral conditioning to learn, they can be told what to do. This includes children who cannot use speech for communication; they understand language, they are just unable to verbally express themselves.
The words of child expert Fred Rogers of Mr. Rogers’ Neighborhood are worth remembering:
When young children get angry, they sometimes hit or bite or kick. That doesn’t mean they’re ”bad.” That’s just how the show they’re mad. They don’t yet have the words to tell us how the feel.
Operant conditioning specifically and behaviorism in general, is also included in the certification because it motivates a child to do something. A rat does not typically do summersaults, but with enough reward and/or punishment contingencies, it can be trained to do summersaults.
But to apply this to children with autism requires the therapist assume that these children do not want to learn. This is a flawed assumption. Children with autism, like neurotypical children, like all children, want to learn. The “problem” is not one of the child’s behavior, it is the inability of the therapist to know how to help the child.
Neurology and neuro-imagery shows us that children with autism have language deficiencies. Their neurology and language difficulties are root causes of why a child with autism struggles in social interactions and academic setting. These are NOT behavior problems. Behaviorism is a flawed theoretical foundation upon which to base an autism certification. PERIOD.
- Despite the often-repeated “40 years of research affirming its effectiveness and providing evidence of substantial, lasting improvements in the lives of individuals with autism,” the evidence underlying behavioral therapies in the treatment of ASD is in fact weak, contradictory, and at times, contravening.
TRICARE Large-Scale Study of ABA:
ABA failed! TRICARE is the military’s health insurance program. They began covering Applied Behavioral Analysis (ABA) services in 2014. In 2017, as part of the National Defense Authorization Act for Fiscal Year 2017, the Department of Defense initiated a Comprehensive Autism Care Demonstration, a two-year study of the effectiveness of ABA. (3) “It’s labeled a “demonstration” because the effectiveness of applied behavioral techniques for autism remains unproven.” (4) The demonstration targets the “nearly 15,000 military children with autism who receive ABA services, usually 20 or more hours of therapy per week, to learn desired behaviors and douse undesirable behaviors.” (5) It is scheduled to be completed in 2023.
Three outcome metrics will have been collected at the completion of two years of treatment, though because of two-year collection requirements only one was reported at this time. Results from only the Pervasive Developmental Disabilities Behavior Inventory (PDDBI) designed to assess the effectiveness of treatments for children with pervasive developmental disabilities, including ASD, could be reported at this time. The other two measures require at least two years of treatment, so could not be reported. These were the the Vineland Adaptive Behavior Scales, a measure of adaptive behavior functioning, and the Social Responsiveness Scale, Second Edition (SRS-2), a measure of social impairment associated with ASD.
Based on results from 1,611 children, after one year the demonstration found that 76% of the children had shown little or no change in in their PDDBI score, only, 16% had improved, and 9% has worsened.
Research on ABA-like therapies:
While advocates of ABA refer to the 40 years of research, it is only Early Intensive Behavioral Intervention (EIBI) that has clear research support. But EIBI requires 20-40 hours per week of treatment, often for multiple years. WebMD, not a rigorously reviewed citation, but one that is commonly used by lay people, states, “To get the most benefit from applied behavior analysis, your child will need extensive one-on-one therapy for 20 to 40 hours each week. A drawback is that this type of intensive therapy is expensive.”
Evidence supporting many ABA intervention is based on small-sample studies that do not have “gold-standard” experimental designs (Roane, et al., 2016). Research reviews and meta-analyses of EIBI therapies that cumulatively show positive effects, also note the variability in results from none to some, with the amount of support dependent upon the outcome measures that were used. Definitions of what exactly was included in the EIBI intervention differ across studies (Caron, et al. (2017). Descriptions of how the intervention was implemented are typically absent or vague, making it difficult at best to know what exactly caused the results. Moreover, despite increasing understanding of the neurology underlying autism, the neurological connection to ABA remains unspecified (Fava & Strauss, 2014).
Summary of the Behavior-based Research:
To presume that ABA is worthy of a Certification of expertise, ignores both research evidence and anecdotal reporting of the negative consequences or non-effectiveness of ABA. At a minimum any medically-related certification, and especially one referred to by ASHA, should follow the principles attributed to the Hippocratic oath: “First do no harm” , and “Practice two things in your dealings with disease: either help or do not harm the patient.” The research evidence fails to meet minimum these standards: in fact, behavioral treatments may harmful.
If in fact ABA-related interventions are or even may be maladaptive strategies, they should not be the foundation of an autism certification, and ASHA should work to obstruct the use of any such certification. It is not merely a disservice to practicing SLPs, but as more research emerges, could potentially be considered malpractice.
- The Certification ignores the extensive emerging neuroscience and cognition research underlying our understanding of ASD, which have no conceptual or scientific relation to behavioral interventions.
New research on understanding autism:
The amount of research in neuroscience and cognition is exploding and shedding new light on our understanding of autism. These include neuro-cognition, psychology, traumatic brain disorders, neuro-imaging, pediatrics, etc. New constructs in executive functioning like theory of mind, social cognition, language disorders, and inner speech, all have growing bodies of research with children with autism. SLPs who work with individuals with autism would benefit from an assessment that includes this research. Just a few of these researchers, many of whom lead autism research centers include: Simon Baron-Cohen, Elizabeth Pellicano, Charles Fernyhough, David Williams, Lynne Hewiitt, Marcel Just, Nancy Minshew, Diane Williams, Shelly Channon, Marcel Just, Jill Fahy, Pawan Sihna, Lucy Livingston, and others. Reading studies and papers by these researchers provides a more robust and in-depth understanding of autism, which would be essential for any certification as an autism expert.
No autism-related certification should ignore or avoid the exploding knowledge of executive functioning, neuroscience, and cognition that is the foundation for understanding autism. Practicing SLPs need to stay current on emerging neuroscience research that adds to their understanding of autism. Ironically, this certification fails to achieve this objective.
- The diagnostic approaches underlying behavioral analysis are inherently subject to errors of interpretation.
The typical Functional Behavioral Assessment (FBA), sometimes referenced as Functional Behavioral Analysis, is fundamentally biased against a neurocognitive understanding of autism, in favor of a behavioral one. This is especially regrettable because FBA is required by Section 300.530(f) of the Individuals with Disabilities in Education Act (IDEA). Unfortunately, the research paradigm used in the field of Education in 1997 when IDEA was passed, was centered on behaviorism. While IDEA has been reauthorized, most recently in 2017, these reauthorizations have not kept up with our current understanding of the etiology and needs of children with special needs. Moreover, the initial research upon which the requirement for FBA was conducted on a limited segment of the disability population, without any consideration of the autistic spectrum populations specifically. In other words, the foundation upon which the use of FBA applies to autistic individuals is shaky at best, and more likely completely inappropriate.
In general, FBA requires the analyst to analyze a behavior by looking at the situational antecedents of the “inappropriate” behavior, i.e., the environment before the behavior occurred and then the situational consequences of the “inappropriate” behavior. Understanding the ABCs of a situation (Antecedent – Behavior – Consequence) is essential to any ABA-like intervention.
It follows the basic motivational model underlying behaviorism: The reason the individual acted the way he or she did in that situation was that individual had learned that the resulting behavior has resulted in either a reward (getting what he or she wanted) or avoided a punishment (not having to do something that he or she didn’t want to do). Inappropriate behaviors are generally attributed to a desire to Escape, Refuse, Avoid, or to Seek Attention.
This ABC analysis precludes any consideration that the true cause underlying a behavior is not motivational, but is instead neurological. The child did not act in response to reward or punishment, but because he/she did not understand the request, or interpreted the request literally when it was intended imprecisely or abstractly, or that the individual may have required more time to cognitively process what was meant and what to do than the requesting individual expected, or that the individual had deficient problem-solving ability. For example, “put your things away” only makes sense when the listener knows what is meant by “things,” and knows where the things should be “put away.” If the child responds, “I don’t know what you mean,” do doesn’t do anything for fear of doing the wrong thing, these responses are often interpreted as defiance or obstinance.
An analogy helps to clarify the problem with FBA for children with autism. Imagine a request is made to a deaf child, “Get out of the way” (Antecedent condition), the child does not move (the Behavior), the child is knocked down. (Consequence). An FBA analyst could conclude that the child was intentionally refusing to comply or seeking attention. This would obviously be a wrong conclusion. Of course if the analyst knew the child was deaf, the analyst would never have attributed the behavior motivationally. The analyst would simply conclude that it was not the deaf child’s fault; the child couldn’t hear the request. The therapist (or teacher) would not then create an individual behavioral plan incentivizes the child to listen more carefully. Similarly, autistic deaf] children act the way they do because they have autism [deafness].
The research behind FBA was not designed with autistic children in mind. It has been inappropriately adapted and applied to them. Autistic children act as they do because they make unseeable neurological or cognitive processing errors — not because, as a behavioral assessment would conclude — they are motivated to act inappropriately.
B. Unanticipated Consequences on the Reputation of ASHA
Per the Autism Specialty website (www.autismspecialty.org), the Autism Specialty Certification is a product of the American Board of Autism Spectrum Disorders. The American Board of Autism Spectrum Disorders is an independent 501c3 organization, but does not appear to have an independent website. The members of the executive committee, posted on the autism Specialty website are Dr. Lynn Kern Koegel and Dr. Stephen M. Camarata. No other information about the American Board of Autism Spectrum Disorders is provided.
There appears to be confusion among the neurotypical community including SLPs, as to the relationship between Autism Speciality and ASHA. The Autism Specialty website makes it appear that there is a strong the relationship between it and ASHA. ASHA is prominently listed in the About Us section of the Autism Specialty website. The relationship description is no doubt precisely accurate, but it is also convoluted. However, the implication is clear: the American Board of Autism Spectrum Disorders, and by extension the Board Certified Specialist in Autism Spectrum Disorders (BCS-ASD), is working with the approval of, and under the guidance of ASHA.
As they state,
Clinical Specialty Certification enables a speech-language pathologist or audiologist with advanced knowledge, skills, and experience beyond the Certificate of Clinical Competence (CCC) to be identified by colleagues, employers, referral and payer sources, and the general public as a Board Certified Specialist (BCS) in a specific area of clinical practice.
The [American Board of Autism Spectrum Disorders] relates to the Autism Specialty through CCSC. The council serves as both a resource for the Board and an oversight function to assure that the standards set by the Autism Specialty are being maintained and that as changes to the program are made the consumer is being fully considered. The Autism Specialty submits an annual report for review by CCSC.
Note: CCSC is the CFCC’s Committee on Clinical Specialty Certification. CFFCC is the Council for Clinical Certification in Audiology and Speech-Language Pathology (CFCC) through the (CCSC).
- Failure to recognize Conflict of Interest
ASHA has a well deserved reputation demanding its researchers and practitioners clearly acknowledge any conflicts of interest that may be actual or perceived by those that read their journal and attend their conferences, workshops and seminars. So it is disturbing that no such attention was given to the conflict of interest inherent in an SLP “certification,” nor was it recognized at the recent national ASHA Conference where a session by the sponsors and developers of the certification were presenting.
The Certification was developed by an ABA advocate. The Pivotal Response Treatment is a form of ABA. The Certification knowledge areas come directly from ABA, and other knowledge or research in the autism areas is either not mentioned, or is considered only in the context of terminology.
If ASHA is truly interested in an autism certification, then it should be guided by an advisory board made of of researchers from diverse backgrounds, not only from one school of thought.
- Loss of respect among ASD researchers, including severed membership in favor of alternative research organizations.
As with interest in autism generally, the number of ASD researchers is growing dramatically, as is the number of autism research journals. A growing number of autism researchers are focused on neuroscience executive functioning and cognitive science. The number of research associations is expanding, many of whose members are either not interested in behavioral interventions, or antagonistic to them, for example, INSAR, Autism-Europe, etc. Should ASHA be prominently associated with a behavior-based intervention, it is not unlikely that many of these researchers will sever their association with ASHA, or worse, begin to hold ASHA in disdain.
- Loss of respect among ASD practitioners, including severed membership in favor of alternative ASD-related practitioner organizations.
Recently my wife, Janice Nathan, MS, CCC-SLP, and I were invited to participate in an NSF-funded program of the University of Pittsburgh Innovation Institute, called Pitt Ventures First Gear. As a requirement of that program, we were required to conduct at least 20 interviews with researchers and practitioners interested in autism. At the Pennsylvania Speech-Language Hearing Association Convention (PSHA) we met with numerous SLPs from across the state. The interviews were illuminating and disturbing. From several SLPs who were being forced to use it, we were told, “SLPs hate ABA.” Despite full funding from the PA Department of Education for ABA instruction, at least two Special Education Districts n Pennsylvania (the state’s “Intermediate Units”) were refusing to attend the training despite full reimbursement; their staff refused to implement ABA because of negative reactions from clients and their parents. One university with a specialty masters degree in autism, told us that among their biggest challenges was “unlearning” of ABA by students with BCBA Certifications.
These reports were anecdotal, but reflected a growing negative reaction to behavioral interventions by practitioners.
- Loss of credibility among the ASD and neurodiversity populations, including outright rejection.
Rejection by those in the neurodiversity community, including those on the spectrum, as well as practitioners and researchers is well documented. Their negative reaction to how the Autism Certification session was conducted at ASHA is also well known. After being told they would be heard and would have a chance to provide input into the certification process, they found the certification was fait accompli.
Any review period or guidelines that focus strictly on the individual tasks and knowledge areas, does not allow for discussion of the more fundamental problem that the certification is based substantially if not solely on behavioral principles and technique, which many in this community with first hand knowledge find dysfunctional and harmful.
ABOUT BARRY R. NATHAN, PhD
Barry R. Nathan, PhD is an organizational psychologist and founding director of Concierge Pittsburgh, a regional initiative to retain and attract African American professionals in Pittsburgh. Barry has a brother-in-law with autism; his wife, Janice Nathan, is a certified speech-language pathologist who specializes in helping children with autism and other neurodevelopment disorders.
Barry is co-author with Janice Nathan, M.S., SLP-CCC, of Building Reasoning and Problem-solving Skills in Children with Autism Spectrum Disorders: A Step by Step Guide to the Thinking In Speech® Intervention (2018; Jessica Kingsley Publishers), which earned he and Janice participation in the Pitt Venture First Gear program, a National Science Foundation funded program of the University of Pittsburgh Innovation Institute. In September, he and Janice presented, “Turning Behavior and Anxiety into Communication for Social Problem-Solving by Thinking in Speech®” at the 2019 12th Annual International Autism Europe Congress, in Nice, France.
Barry is co-Principal Investigator with Dr. Valire Carr Copeland of the University of Pittsburgh School of Social Work on three research grant proposals on “Addressing Autism in African American Families.” He was the facilitator of a panel discussion on “Autism and the School-to-Prison Pipeline,” presented at the July, 2019, University of Pittsburgh School of Education Center for Urban Education Summer Educator Forum (CUESEF). Barry was also a co-presenter with Jamie Upshaw, M.A., Executive Director of Autism Urban Connections, Inc., at the 2019 Greater Pittsburgh Nonprofit Partnership Summit, on “Addressing Autism in the Black Community: Autism Urban Connections, Inc.”
2. Behaviorism’s roots go back to early 20th Century psychologists, i.e., John D. Watson, Eric Thorndike and others, but it is B. F. Skinner, to whom modern behaviorism can be traced.
3. TRICARE Comprehensive Autism Care Demonstration Program_2_2019. https://health.mil › Congressional-Testimonies › 2019/10/25
6. Therapies for Autism Spectrum Disorder. https://www.webmd.com/brain/autism/autism-therapies-aba-rdi-and-sensory-therapies#1
7. Roane, H. S., Fisher, W. W., & Carr, J. E. (2016). Applied Behavior Analysis as Treatment for Autism Spectrum Disorder. Journal of Pediatrics, 175, 27-32.
8. Caron, V., Bérubé, A., & Paquet, A. (2017). Implementation evaluation of early intensive behavioral intervention programs for children with autism spectrum disorders: A systematic review of studies in the last decade. Evaluation and Program Planning, 62, 1–8.
9. Fava, L, & Strauss, K. (2014). Response to Early Intensive Behavioral Intervention for autism—An umbrella approach to issues critical to treatment individualization. International Journal of Developmental Neuroscience, 39, 49-58.