Intensive early behavioral intervention: a letter of support

Bernard Rimland, Ph.D.
Autism Research Institute
4182 Adams Avenue
San Diego, CA 92116

“We are parents of a three-year-old autistic child. After reading Let Me Hear Your Voice and talking with other parents who have tried early behavioral intervention, we have become very eager to enroll our child in an intensive early intervention behavioral program. The school officials are skeptical and reluctant. Would you be willing to write us a letter of support, to help us get this kind of treatment for our child?”

After responding individually to the first dozen or so such requests, I wrote a generic “To whom it may concern” letter of support, which has been sent to families throughout the U.S., Canada and, recently, even Australia, who have phoned, faxed, or written for help. Since there are many other families who might also benefit, here, in print, is my letter of support:

To Whom It May Concern:

As a psychologist with over 30 years of experience in research in the field of autism, and as the editor of the Autism Research Review International, I want to go firmly on record as supporting the value of intensive early behavioral intervention as a modal- ity—actually the most important available modality—for bringing about improvement in most autistic children. My support for the value of intensive early behavioral intervention is based on two lines of evidence:

Research: There is no question whatever that the research evidence strongly favors the value of intensive early behavioral intervention in autism. The first study, published in 1985 by Fenske et al., of the Princeton Child Development Institute, in Annals of Intervention in Developmental Disabilities (Vol. 5, pages 849-56) reported that 60 percent of the autistic children enrolled in the program before age five had improved enough to be successfully mainstreamed (not just “included”).

The PCDI study attracted little attention. The major impetus for the current high level of interest in intensive early behavioral intervention programs in autism came with the publication of the controlled experiment in which 19 children involved in an intensive intervention program were compared, on a number of measures, with 40 control group children who participated in less intensive programs. Nine in the “intensive” group could be mainstreamed, versus only one of the controls. The strongly positive results of this study at UCLA by Ivar Lovaas and his colleagues were so unexpected that the editors of the Journal of Consulting and Clinical Psychology subjected the report to special review by three respected associate editors prior to its publication (Vol. 65, No. 1, 1987, pages 3-9). Subsequently, a followup article was published in the American Journal on Mental Retardation (Vol. 4, 1993) in which McEachin, Smith and Lovaas reported that the excellent educational progress and normal social achievement, on all measures, of the “intensive” group was continuing through their teenage years.

A number of highly respected professionals were invited to comment on this most recent report, and their comments, almost uniformly very favorable, were published in the same issue.

Similar highly positive results, based on an early intensive intervention program, were published by Harris et al., of Rutgers University, in the Journal of Autism and Developmental Disabilities (Vol. 21, No. 3, 1991, pages 261-290). While the PCDI and UCLA studies used low-functioning autistic children, the Rutgers study children were mildly to moderately affected.

Clinical Evidence: Since the publication of the Lovaas study I have been contacted by numerous parents throughout the United States who have undertaken early intensive behavioral intervention with their own children, sometimes on a home program basis, and sometimes through their school systems. I have been very favorably impressed with the consistently strong endorsements for the early intervention programs that I have received from these families. One mother telephoned me recently to report that her son had shown more improvement in the three weeks in which he had been in the highly intensive “Lovaas” program than she had seen in the previous three years in his regular school program, which had been specifically designed to help autistic children. Such enthusiasm is not unusual.

Misconceptions: When I first began writing and lecturing about behavior modification in 1965, two misconceptions were prevalent. Unfortunately, the same two misconceptions are prevalent today.

Some critics of behavioral intervention claim that intervention produces children with rigid, robot-like behaviors, like trained seals. That is absolute nonsense. In her excellent book Let Me Hear Your Voice, author Catherine Maurice tells how her two severely autistic children, both of whom were diagnosed as autistic by several outstanding neurologists and psychiatrists in New York City, have recovered to the point that there is no reason to consider them as other than normal, largely as a result of an intensive home-based early intervention behavioral program. I have recently spoken to Ira Cohen, Ph.D., and Richard Perry, M.D., who are familiar with the two children described in Catherine Maurice's book. They report that they have seen no signs of autism in these children, and in fact have written an article to that effect which is scheduled for publication, in the near future, in the Journal of the American Academy of Child and Adolescent Psychiatry.

The second misconception is that behavioral intervention commonly entails the use of aversive stimuli. Not true! Behavioral intervention uses a great deal of positive reinforcement, and even mildly aversive stimuli, such as a loud “no,” are rarely, if ever, required. (Aversives were used more often in the early days.)

Recovery From Autism: Why is there such skepticism about the effects of early behavioral intervention? No doubt some are skeptical, understandably, because autism is known to be a biological disorder, and it may seem improbable that a behavioral treatment could be so effective. Do not underestimate the body’s ability to accomplish nearly incredible feats—given highly focused, intensive, long-term training. Consider the remarkable skills of an Olympic gymnast—and the intensity of the training required. The amazing feats of the gymnast become possible only through intensive training. The evidence shows that it is possible for at least some autistic children to learn how to overcome their disability, if they start young and the practice is really intensive and one-on-one, 30+ hours per week.

But just what is it that they must practice, to overcome autism? I addressed this question in my 1965 paper, “Operant Conditioning: Breakthrough in the Treatment of Mentally Ill Children:”

No one knows why operant conditioning [now called behavior modification] works, nor why the changes in behavior generalize and apply to so many new behaviors. My own theory is that the operant training, in addition to teaching the specific behaviors, also teaches the child how to direct and focus his attention. Tuning in— learning how to focus our attention and deciding what to pay attention to—comes so naturally to us that we take it for granted. But you can’t learn unless you can pay attention…. {Autistic] children, I suggest, need to learn how to concentrate, focus and direct their attention. Without specific immediate motivation—not long-range motivation such as a college degree—without a specially designed program which allows them to proceed in small steps, many will never learn. With operant training, the autistic child not only learns, he learns how to learn.

When I wrote those words, 30 years ago, I did not realize how well even severely impaired autistic children could learn to deploy their attention effectively, if the circumstances—intensive behavior modification—required that they learn to attend. In that same paper (which was based on the talk I gave in founding the Autism Society of America in 1965), I also said, “The value of placing children in such a firm, structured classroom situation with other children—similar to themselves, retarded, or normal—cannot be overstated. Once the child’s behavior and attention is under control, the family and teachers can take over his further training and socialization…. If the child’s teachers and his family are insistent that the child conform and improve, and they employ the principles described above, his improvement will often be remarkable.” (ARI publication #1, for copy send $1 and SASE.)

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