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The Deep Impact of

Applied Behavior
Analysis for
Children with
Autism Spectrum
Disorder
Todd M. Furman and
Alfred Tuminello, Jr.

Keywords: good life, ethics, pervasive developmental ASD, but also for a wide range of people afflicted
disorder not otherwise specified (PPD-NOS), autism, with developmental and behavioral problems. Be-
early intensive behavioral intervention (EIBI) cause preaching to the choir wins no new converts,
Potter’s doubts and criticism are the focus here.
Before responding to Potter’s objections, some

I
f applied behavior analysis (ABA) works self-disclosure is in order. The genesis for Furman
as claimed by Furman and Tuminello (2015), and Tuminello (2015) was not to show a connec-
then both Schlinger (2015) and Potter (2015) tion between Aristotle’s concept of flourishing,
agree that ABA could, in principle, be an aid for Autism, and ABA per se. Rather, the prime motiva-
solving many more problems than just those as- tion was to shed light on the fact that ABA can fa-
sociated with autism spectrum disorder (ASD). cilitate tremendous results for a sizable percentage
Does ABA work for children with ASD as Furman of children with ASD—results that would count
and Tuminello claim? Schlinger believes that ABA as a good life by most any metric.
can, in fact, solve developmental and behavioral Instead of proposing a new metric for a good
problems associated with ASD for some children life, and having to defend it as well, Furman and
to the point that those children might flourish in Tuminello used the somewhat familiar and strenu-
the Aristotelian sense. On the other hand, Potter ous notion of a good life as offered by Aristotle.
does not believe that ABA can, in fact, elevate The choice of Aristotle’s rubric was somewhat
children with ASD to the level of Aristotelian capricious then. Hence, a full defense against Pot-
flourishing. ter’s objections will not be mounted, except for
Schlinger may be predisposed to agree with Fur- where she has underestimated the deep impact that
man and Tuminello because he is a Board-Certified ABA can have on children with ASD—where the
Behavior Analyst and has probably seen the results accomplishments of children with ASD that have
that ABA can produce not just for children with been treated with ABA are on par with those of
normally developing children.
© 2016 by The Johns Hopkins University Press
272  ■  PPP / Vol. 22, No. 4 / December 2015

Being Prudent: to exist in children recovering from ASD. How-


ever, the true impact of ABA becomes clear when
A State of Mind considering the details of some longitudinal studies
Potter believes that the key element of Aristo- of EIBIs using ABA on children with ASD.
telian flourishing is the virtue of prudence (phro- In follow-up examinations, Sallows and
nesis) (Potter 2015, 265). Prudence is the ability Graupner (2005) reported that 34% of children
to reason correctly about what sort of actions and with ASD that received an EIBI using ABA no lon-
goods lead to human flourishing. But prudence ger meet the criteria for ASD as measured by the
is not contained in just the ability to reason cor- Autism Diagnostic Interview-Revised assessment
rectly about what sort of actions and goods that tool (Sallows and Graupner 2005, 428). To be
lead to human flourishing. The prudent person perfectly clear, the Autism Diagnostic Interview-
must internalize the goodness of said judgment Revised focuses on assessing three main areas:
and actions—she must feel the rightness of the stereotyped behaviors, communication skills, and
prudent goods and acts and these feelings must most important, given Potter’s concerns, social
factor into her motivation to act as such; other- interactions. In this light, Sallows and Graupner
wise there is just the appearance of prudence but (2005) found, in aggregate, that 34% of the chil-
no true prudence. dren studied came to communicate, behave, and
The problem Potter has with Furman and interact socially at the same levels achieved by
Tuminello’s (2015) claims of children with ASD normally developing children.
flourishing as a result of an early intensive be- Zachor, Ben-Itzchak, Rabinovich, and Lahat
havioral intervention (EIBI) with ABA is this. She (2007) used the gold standard for ASD assessment,
believes that ABA may allow children with ASD the Autism Diagnostic Observation Schedule, to
to model appropriate (i.e., prudent) behaviors compare pre- and post-EIBI interventions using
but not feel them in the appropriate way (Potter, ABA. The Autism Diagnostic Observation Sched-
264). For example, a child might go through all ule is an interactive assessment tool that constructs
of the appropriate external motions of friendship social situations in which four domains of ability
toward another child, but if she does not feel the are assessed: language and communication, re-
friendship, there is no real friendship; there is no ciprocal social interaction, play, and stereotyped
virtue of friendship in place. Hence, Potter asks, behaviors. Zachor et al. (2007) discovered that
Is there anything more to ABA training than de- 20% of the treated children moved off of the au-
veloping a skill set by which people with ASD can tism spectrum; 20% no longer qualified as autistic.
cope better in the world? Do persons with ASD McEachin, Smith, and Lovaas (1993) discov-
ever achieve a normal emotional life? The answer ered an even greater percentage of children that
to both questions is an emphatic yes. had been diagnosed with ASD that had been
normalized after their EIBIs with ABA. The as-
Evidence for the Deep Impact sessment instruments used by McEachin et al.
of ABA to measure intellectual, social, and emotional
functioning were the Wechsler Intelligence Scale
for Children-Revised, The Vineland Adaptive
The Studies Behavior Scales, and the Personality Inventory
Furman and Tuminello (2015) pointed to for Children.
research (Cohen, Amerine-Dickens, Smith 2006; Results such as these have some researchers
Lovaas 1987; Sallows and Graupner 2005) that working on defining the finishing line of recovery
showed that children with ASD that receive an from ASD (Granpeesheh, Tarbox, and Dixon
EIBI using ABA may achieve normal levels of 2009; Helt et al. 2008).
functioning. What may not have been so obvious Simply because a child that was diagnosed with
was the fact that the normal levels of functioning ASD no longer meets the criteria for ASD does
included the emotional component Potter doubts not mean that such a child will flourish in the Ar-
Furman and Tuminello / Applied Behavior Analysis for ASD  ■ 273

istotelian sense. After all, as Potter (2015) points social mores, and so on. Fast forward to five years
out, the standard for flourishing in the Aristotelian later. Peter is finishing second grade in a regular
sense is very, very high and requires a bit of good classroom earning all As and Bs. Peter has friends
luck as well (e.g., health and wealth) to every fully and Peter gets happy, mad, sad, proud, and so on
reach it. But what can be said, based on results like at the right times, about the right things, toward
those reported by Sallows and Graupner (2005) the right people, for the right end, and in the right
and Zachor et al. (2007), is that a significant per- way, as much as any other second grader. Peter fits
centage of children can overcome ADS to have just in so well now that he received an award, voted
as much of a chance at flourishing as a normally on by his peers, for exemplary citizenship. Because
developing child. And this fact is unknown by far of his EIBI using ABA, Peter has just as much of a
too many people. chance at Aristotelian flourishing as the next kid.
One note concerning Potter’s doubts about the
appropriate mental lives of children with autism is Conclusion
in order. As Schlinger (2015) points out, psychol- All hope is not lost for children with ASD.
ogy qua behaviorism really started to become a With an appropriate intervention, a significant
real science and show tangible results when it jet- number of children with ASD can be normalized;
tisoned mentalism. Hence, the behaviorist is not a significant number can flourish just as much as
going to give much credence to Aristotle’s demand any other child might.
that certain sorts of mental states accompany Society is in possession of a great power—the
prudent actions for the person to be prudent and Board-Certified Behavior Analyst. Let us hope that
flourish. According to the behaviorist, the appro- society lives up to its corresponding responsibility
priate actions are all there is for assessing prudence and uses Board-Certified Behavior Analysts to the
and flourishing. Behaviorists are unapologetic fullest extent possible.
epistemological externalists.
Acknowledgment
Anecdotal Evidence
The authors thank the journal referees for their
In agreement with Sherman (1989), Potter thoughtful and helpful comments. We also profited
rightfully claims that, according to Aristotle, we greatly from conversations with Dr. Charlotte
cannot live well (i.e., flourish) as social beings Carp, Dr. Cam Melville, Dr. Tracy Leper, Dr.
without proper emotional engagement with oth- Hanno Bulhof, and Dr. Cheryl Ware, and from the
ers. Potter wonders aloud whether children with moral support of Andrea Furman and Katie Blum.
ASD will ever be able to
be afraid, for instance, or to be confident, or have References
appetites, or get angry, or feel pity and in general have Cohen, H., M. Amerine-Dickens, and T. Smith. 2006.
pleasure or pain… [in general, to have these] feelings Early intensive behavioral treatment: Replication of
in the right times, about the right things, toward the the UCLA model in a community setting. Develop-
right people, for the right end, and in the right way. mental and Behavioral Pediatrics 27, no. S1:45–55.
(Potter 2015, 265) Furman, T., and A. Tuminello. 2015. Aristotle, autism,
and applied behavior analysis. Philosophy, Psychia-
Personal experience says, yes they can. Peter
try, & Psychology 22, no. 4:253–61.
Parker (not his real name) was diagnosed at the Granpeesheh, D., J. Tarbox, and D. R. Dixon. 2009.
age of 4 with ASD and an EIBI was put into Retrospective analysis of clinical records in 38 cases
place shortly thereafter. The EIBI consisted of of recovery from autism. Annals of Clinical Psychia-
year-round ABA on the order of 20 to 40 hours try 21:195–204.
per week. Helt, M., E. Kelley, M. Kinsbourne, J. Pandey, H. Boor-
Even with Peter Parker’s intervention on its stein, M. Herbert, and D. Fein. 2008. Can children
with autism recover? If so, how? Neuropsychology
way, it seemed dubious to Peter Parker’s parents
Review 18:339–66.
whether Peter would ever learn to read or write,
initiate a conversation, have friends, understand
274  ■  PPP / Vol. 22, No. 4 / December 2015

Lovaas, O. I. 1987. Behavioral treatment and normal Sallows, G. O., and T. D. Graupner. 2005. Intensive
educational and intellectual functioning in young behavioral treatment for children with autism: Four-
autistic children. Journal of Consulting and Clinical year outcome and predictors. American Journal on
Psychology 55:3–9. Mental Retardation 110: 417–38.
McEachin, J. J., T. Smith, and O. I. Lovaas. 1993. Long- Sherman, N. 1989. The fabric of character: Aristotle’s
term outcome for children with autism who received theory of virtue. Oxford: Clarendon Press.
early intensive behavioral treatment. American Jour- Schlinger, H. D. 2015. Behavior analysis and the good
nal on Mental Retardation 97:359–72. life. Philosophy, Psychiatry, & Psychology 22, no.
Potter, N. N. 2015. Doing right and being good: What 4:267–70.
it would take for people living with autism to flour- Zachor, D. A., E. Ben-Itzchak, A. Rabinovich, and E.
ish. Philosophy, Psychiatry, & Psychology 22, no. Lahat, E. 2007. Change in autism core symptoms
4:263–5. with intervention. Research in Autism Spectrum
Disorders 1:304–17.
About the Authors  ■ 333

About the Authors

Todd M. Furman is Professor of Philosophy at Professor in the Department of Psychiatry at the


McNeese State University and on the editorial l’Université de Montréal. Her areas of academic
board of the journal Teaching Philosophy. Aca- interest are in bioethics and the philosophy of
demic interests include epistemology, philosophy psychiatry. Dr Gupta is widely published on the
of religion, critical thinking, and ethics. Todd subject of ethics and evidence-based medicine
Furman is currently working on a book, Honor in psychiatry. Her research monograph on this
Among Thieves: An Exploration of Ethics in Poker topic was published by Oxford University Press
and the World Beyond. He can be contacted via in 2014. She can be reached via email at mona.
e-mail at tfurman@mcneese.edu. gupta@umontreal.ca.

Richard G. T. Gipps is a Clinical Psychologist pro- Aaron J. Hauptman is a Child and Adolescent
viding psychotherapy for the University of Oxford Psychiatry Fellow at New York University. He is
and in private practice. His special interest is the interested in adult and pediatric neuropsychiatry.
philosophical understanding of, and psychoana- Two recent publications include “The Differential
lytical psychotherapy for, schizophrenic psychosis. Diagnosis and Treatment of Catatonia in Children
He can be contacted via email at richard.gipps@ and Adolescents” co-authored with Dr. Sheldon
admin.ox.ac.uk. Benjamin and forthcoming in The Harvard Review
of Psychiatry and Neuroscience and “Neurosci-
William E. Greenberg is Psychiatrist-in-Chief of ence of Morality for the Mental Health Practitio-
Beth Israel Deaconess Medical Center. He served ner: A Review” published in Psychiatric Times.
as Residency Training Director at Beth Israel Hos-
pital, Boston from 1987 to 1994 and of the Har- Ginger A. Hoffman is Assistant Professor of Phi-
vard Longwood Psychiatry Residency from 1994 losophy at St. Joseph’s University in Philadelphia,
to 2011. He is Assistant Professor of Psychiatry at Pennsylvania. She received her PhD in philosophy
Harvard Medical School. Dr. Greenberg recently from MIT, where her dissertation focused on the
published “Changes in Residency Training over ethics of antidepressant treatments, and her PhD in
the Past Quarter-Century: Reflections of a Long- neuroscience from Yale University, where her dis-
time Program Director” in Academic Psychiatry. sertation investigated the basic biology underlying
He can be contacted via email at wgreenbe@ the mechanisms of antidepressant treatments. She
bidmc.harvard.edu. researches and teaches in philosophy of psychiatry,
neuroethics, feminist philosophy, philosophy of
Mona Gupta is a Consultation-Liaison Psychia- mind, and applied ethics. Her recent publications
trist and Researcher at the Centre Hospitalier de include: Hoffman, G. A. 2013. Treating yourself
l’Université de Montréal. She is also Assistant as an object: Self-objectification and the ethical

© 2016 by The Johns Hopkins University Press


334  ■  PPP / Vol. 22, No. 4 / December 2015

dimensions of antidepressant use. Neuroethics Henry D. Schlinger, Jr., is Professor of Psychology


6:165–78, and Hoffman, G. A., and J. Hansen. at California State University, Los Angeles. He is
2011. Is Prozac a feminist drug? The International the former editor of The Analysis of Verbal Behav-
Journal of Feminist Approaches to Bioethics 4, ior and The Behavior Analyst and the author of
no. 1: 89–120. She can be reached via email at three books, including A Behavior Analytic View
gingerahoffman@gmail.com. of Child Development. Academic interests include
basic learning processes, schedules of reinforce-
Ian James Kidd is an Assistant Professor at the ment, child development, conceptual issues in
Department of Philosophy, University of Notting- behavior analysis and psychology, and verbal be-
ham. His research interests include the experience havior. Recent publications include: “What would
and value of illness, the nature of a religious life, it be like to be IBM’s computer, Watson?” The
and philosophical virtue theory and intersects Behavior Analyst, 2012, 35, 37–44, and “Behavior
philosophy of illness, philosophy of religion, and analysis and behavioral neuroscience” Frontiers
history of philosophy. He can be contacted via in Human Neuroscience 17 April 2015. He can
email at ian.kidd@nottingham.ac.uk. be contacted via e-mail at hschlin@calstatela.edu.

Robert S. Kruger is a Clinical Child Psychologist Anastasia Philippa Scrutton is a philosopher with
with a private practice in Westport, Connecticut. particular interests in religion, emotion, and psy-
He received his undergraduate degree in psychol- chiatry. Some recent publications include “Can
ogy from Columbia University and his doctorate being told you’re ill make you ill? A discussion
from Yale University. He was a postdoctoral fellow of psychiatry, religion, and out of the ordinary
at Yale in psychiatric epidemiology studying the experiences” in Think: Philosophy for Everyone
prevalence of childhood psychiatric disorders, a (forthcoming); “Suffering as potentially transfor-
postdoctoral associate at Yale in psychology study- mative: A philosophical and pastoral consideration
ing the effect of violence on television on children, drawing on Henri Nouwen’s experience of depres-
and a postdoctoral fellow in philosophy at Yale sion” in Pastoral Psychology, 2015, 64.1, 99–109,
studying philosophy of mind and phenomenology. and “Divine passibility: God and emotion” in
He has been a Clinical Instructor in Psychiatry at Philosophy Compass, 2013, 8.9, 866–74. She can
Yale and Cornell. His most recent work has been be reached via email at t.scrutton@leeds.ac.uk.
on clinical theory in the diagnosis of autism. He
can be contacted via email at drrskruger@gmail. John Swinton is Professor in Practical Theology
com. and Pastoral Care in the School of Divinity, Re-
ligious Studies, and Philosophy at the University
Nancy Nyquist Potter has published extensively of Aberdeen. He has a background in mental
in the interdisciplinary field of philosophy and health nursing and healthcare chaplaincy and has
psychiatry, as well as in feminist ethics and po- researched and published extensively within the
litical philosophy. Her current research is on the areas of practical theology, mental health, spiri-
connections between theories of knowledge and tuality and health and the theology of disability.
ethics, with special attention to nosological and He is the Director of Aberdeen University’s Centre
diagnostic issues, and on the relationship between for Spirituality, Health and Disability. He can be
voice, silence, and uptake, in particular for patients reached at j.swinton@abdn.ac.uk.
living with mental illness. Her last book-length
publication was a critical analysis of borderline Alfred Tuminello Jr. is a Board-Certified Behavior
personality disorder (Oxford University Press, Analyst and Director of the McNeese Autism
2009) and her newest book, The Virtue of Defi- Program. He has engaged in research designed to
ance and Psychiatric Engagement, is forthcoming further the knowledge of best practice procedures
2016 (Oxford University Press). She can be con- for individuals with self-care difficulties, including
tacted via email at nancy.potter@louisville.edu. eating aversions, and medical regimen compliance
difficulties. He may be contacted via email at atu-
minellojr@mcneese.edu.
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