Differential diagnosis resources for ADHD vs trauma vs autism

[bluecolourskies]

Hello, the primary focus of my training and work has been with forensic assessment. I am fairly confident in my skills for performing differential diagnosis with psychosis based disorders vs substance use vs personality disorders vs something else.

However, I have since moved on to working more with the general population (still conducting assessment) with both kids and adults, and I find that I am not as familiar with the autism vs adhd vs trauma presentations. And then also ODD with kids in addition to the above. To note, the assessments referral questions are more like “what else are we missing in terms of guiding treatment” vs a specific evaluation to rule out autism, adhd, etc. If I do suspect ASD or ADHD, I typically say that this is beyond the referral question and we need to refer out to someone for these specific diagnoses.
Sometimes the clients come in with these diagnoses already, but I need to be able to tease out if there is something else or more going on. Many do have trauma, IQ is usually between 70-80.

That being said, I did do a year long practicum way back in grad school, in a center that did autism/ADHD/LD evals with kids so it’s not like I am completely unfamiliar, but this was a long time ago.

Because this always seems to come up- I frequently consult with my wonderful colleagues and supervisor but would like to build up my competency in these areas.

Sorry if any of that is unclear!

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[BuckeyeLove]

I feel completely inept with anything spectrum related. At least from the standpoint of standard of care and providing initial dx and recs. Reason is... I've seen so many people who clearly don't know what they are doing diagnosing it left and right, yet I come on here and we have regular posters who are actual EXPERTS (one in particular I'm thinking of) in that area, and it's clear how much nuance is overlooked by many practitioners working in that area. I'm curious to see what others have to say in this thread.

 

[PsyDr]

1) You're having problems because "trauma" is not a diagnosis. It's not even a well defined term, outside of DSM's Criterion A for PTSD. That's a significant problem. If you're trying to attribute a large host of behaviors to exposure to an ill defined event, that practice was abandoned over 100 years ago. So when you're saying trauma, what specifically do you mean? Only a small minority of people who are exposure to Criterion A events develop behavioral effects. Personality factors seem to play a significant role in who develops symptoms and who does not.

2) PTSD is extremely treatable, with high remission rates. This is GREAT news for patients.

3) ADHD is easy. Present at childhood. Not explained by other things, including low IQ. People are trying to expand the diagnosis into behaviors that are beyond its definition. Don't fall for that. The MTA data says stimulants for 2 years combined with behavioral treatment, then no stimulants. 40 years of behavioral data, and 25+ years of imaging data says that the majority of people grow out of it, which supports the conceptualization of the dx being delayed grey matter maturation. At a FSIQ of 70, it would be wise to consider any deficit in attention and executive functioning as potentially consistent with the rest of cognition.

3) ASD is also easy. B criteria is useful in ddx of ADHD. Rule out of low IQ, as an explanation for behavior is useful for ddx in other areas. People are trying to expand this one as well. Don't fall for this. It's a horrible diagnosis, with QoL that is lower than that of pediatric cancer patients. The treatment is behavioral.

4) Clinically, diagnosis is only important because it guides treatment. There are many non-clinical reasons people want a diagnosis (e.g., disability payments, work accommodations, public services, etc). Those non-clinical areas can complicate the clinical relationship, or end it. You have a job to do, and it is wise to stay in that role.

 

[cara susanna]

I work with adults, where this is easier to determine, but generally age of onset and course is the most helpful. Were the ADHD symptoms present prior to the trauma? Have they been present even then the trauma-related symptoms (e.g., PTSD) were less severe? Etc

You also can just reach the point where you say you can't rule ADHD out but can't definitively diagnose it due to overlapping PTSD symptoms, so you do a rule out and say that ADHD can be ruled in or out after the PTSD has been treated. I think a lot of non-psychologists think that testing is some crystal ball, and it's okay (or even good practice, in that it's much better than acting like you know when you really don't) for a psychologist to acknowledge its limitations.

 

[bluecolourskies]

1) You're having problems because "trauma" is not a diagnosis. It's not even a well defined term, outside of DSM's Criterion A for PTSD. That's a significant problem. If you're trying to attribute a large host of behaviors to exposure to an ill defined event, that practice was abandoned over 100 years ago. So when you're saying trauma, what specifically do you mean? Only a small minority of people who are exposure to Criterion A events develop behavioral effects. Personality factors seem to play a significant role in who develops symptoms and who does not.

2) PTSD is extremely treatable, with high remission rates. This is GREAT news for patients.

3) ADHD is easy. Present at childhood. Not explained by other things, including low IQ. People are trying to expand the diagnosis into behaviors that are beyond its definition. Don't fall for that. The MTA data says stimulants for 2 years combined with behavioral treatment, then no stimulants. 40 years of behavioral data, and 25+ years of imaging data says that the majority of people grow out of it, which supports the conceptualization of the dx being delayed grey matter maturation. At a FSIQ of 70, it would be wise to consider any deficit in attention and executive functioning as potentially consistent with the rest of cognition.

3) ASD is also easy. B criteria is useful in ddx of ADHD. Rule out of low IQ, as an explanation for behavior is useful for ddx in other areas. People are trying to expand this one as well. Don't fall for this. It's a horrible diagnosis, with QoL that is lower than that of pediatric cancer patients. The treatment is behavioral.

4) Clinically, diagnosis is only important because it guides treatment. There are many non-clinical reasons people want a diagnosis (e.g., disability payments, work accommodations, public services, etc). Those non-clinical areas can complicate the clinical relationship, or end it. You have a job to do, and it is wise to stay in that role.

By trauma I meant the diagnoses of PTSD/acute stress disorder, etc. was being lazy and didn’t type both out.

And thank you!

 

[bluecolourskies]

For points 3 and 4, any suggested further readings or trainings that are quality resources from trusted people in the field?

Re: point 4- thankfully this is the focus for
me (guiding treatment) and not for the purposes of disability payments, etc.

 

[futureapppsy2]

ASD is also easy. B criteria is useful in ddx of ADHD. Rule out of low IQ, as an explanation for behavior is useful for ddx in other areas. People are trying to expand this one as well. Don't fall for this. It's a horrible diagnosis, with QoL that is lower than that of pediatric cancer patients. The treatment is behavioral.

As someone whose done a fair amount of ASD assessment, I disagree that it's easy, outside of *maybe* very young children with very classic presentations (and even then, you have to rule out speech-language disorders, other developmental disabilities, genetic conditions, etc). As a diagnostic team, we spent a long time trying to agree if a restricted-repetitive behavior was truly restricted enough to meet the criteria or trying to parse out current versus early childhood levels of eye contact, etc. I also disagree that ASD should only apply to, say, completely non-verbal people who engage in constant stimming. The literature shows that people with a lesser degree of symptom severity but who meet the diagnostic criteria still experience a lot of negative outcomes medically, socially/educationally/vocationally, and in terms of secondary mental health diagnoses, and the literature is increasingly suggesting that masking has some serious, harmful consequences over time for a notable amount of higher functioning people. I dislike the way everyone on the internet seems to call themselves "autistic" if they felt socially awkward once or had a hobby as much as the next person and agree that we definitely need to make sure that people meet the actual diagnostic criteria, but I don't think we should ignore higher functioning folks who may be tricker to diagnose but still meet the criteria.

 

[PsyDr]

As someone whose done a fair amount of ASD assessment, I disagree that it's easy, outside of *maybe* very young children with very classic presentations (and even then, you have to rule out speech-language disorders, other developmental disabilities, genetic conditions, etc). As a diagnostic team, we spent a long time trying to agree if a restricted-repetitive behavior was truly restricted enough to meet the criteria or trying to parse out current versus early childhood levels of eye contact, etc. I also disagree that ASD should only apply to, say, completely non-verbal people who engage in constant stimming. The literature shows that people with a lesser degree of symptom severity but who meet the diagnostic criteria still experience a lot of negative outcomes medically, socially/educationally/vocationally, and in terms of secondary mental health diagnoses, and the literature is increasingly suggesting that masking has some serious, harmful consequences over time for a notable amount of higher functioning people. I dislike the way everyone on the internet seems to call themselves "autistic" if they felt socially awkward once or had a hobby as much as the next person and agree that we definitely need to make sure that people meet the actual diagnostic criteria, but I don't think we should ignore higher functioning folks who may be tricker to diagnose but still meet the criteria.

Explain the difference between non impairing symptoms, symptom remission, and symptom masking. The former is diagnostically required, and remission does not refer to symptom absence.

 

[R. Matey]

I work with adults, where this is easier to determine, but generally age of onset and course is the most helpful. Were the ADHD symptoms present prior to the trauma? Have they been present even then the trauma-related symptoms (e.g., PTSD) were less severe? Etc

You also can just reach the point where you say you can't rule ADHD out but can't definitively diagnose it due to overlapping PTSD symptoms, so you do a rule out and say that ADHD can be ruled in or out after the PTSD has been treated. I think a lot of non-psychologists think that testing is some crystal ball, and it's okay (or even good practice, in that it's much better than acting like you know when you really don't) for a psychologist to acknowledge its limitations.

Largely agree with this post though I'll add that I'd be on the lookout for hyperactive symptoms as I could see them being treatment interfering (e.g., sensation seeking = high risk of drug use) even if you're uncomfortable diagnosing ADHD. In an assessment context, I'd ask about any inattentive symptoms (not just sustaining attention), their functional outcomes, age of onset, and how many settings the sx's occurring in. Those non-symptom criteria can sometimes help.

OP, as far as getting competent, it sounds like you're mostly there. Is there someone in your clinic that can look over your reports if you were to take one or two of those ADHD/LD/ODD cases? I'd want to be trained in the ADOS if I were doing autism evaluations, just for CYA purposes.

 

[ClinicalABA]

As someone whose done a fair amount of ASD assessment, I disagree that it's easy, outside of *maybe* very young children with very classic presentations (and even then, you have to rule out speech-language disorders, other developmental disabilities, genetic conditions, etc)...

Yeah- it is pretty easy with the younger kids (as long as you have the appropriate training and resources). There's a lot less differential diagnosis.

As to the OP, I can only comment on the younger kiddos (under 5). Most of these kids present with reported problems with attention and hyperactivity, often related to not being able to play with one thing for any length of time. My typical client is a 24-36 months old, and there is just too much between subjects variation in attention at that age to conclude that all but the most extreme ends of the tail are unusual. I have not (and would never) diagnose adhd in a kiddo that young. Also- there just usually isn't data from multiple settings, so I couldn't meet criteria C anyways. I often find myself explaining to parents that, at that age, sustained play is usually a) pretend or imaginative; and b) language based. If the kid doesn't yet display pretend/imaginative play (due to ASD or other delay in development) and doesn't speak, there is little to "ground" them in sustained play. With the social attributions and language to go with it, toys are just a collection of different physical properties. Once you figure out how it looks, feels, moves, sounds, tastes, etc., you can quickly move on to the next one. This may look like poor attention (ADHD), but it is more a case of too much attention on the non-social parts of the world.

Remember too that paying attention to something that is not too interesting to you is a learned skill. It needs to be taught and differentially reinforced. Part of my job is too know what is interesting to kids at these different development levels, be really good at/with those games/toys/activities, and be able to act in manner that attracts and holds their attention. This is the hard part of diagnosing these younger kids, and it's hard to teach. It's amazing to me (and to many of the parents) that many of these kiddos actually can focus and play with someone else who is playing at their developmental level and in a manner that is goofy/silly enough to hold their attention, without a lot of correction or "discipline" for not following arbitrary rules. Along these lines, I remember doing Barkley "Defiant Children" curriculum groups with parents. By far the most eye-opening, fun, and therapeutic homework was where the parents were instructed to play with their children, whatever the child wanted to play, and without following any rules. Your kid want's to pick another card while wearing their shoes on their hands, you let them do it. They insist on playing the Raiders in TECMO Bowl and you have to be the Bengals, you do it (that reference may date me a little). All the sudden everyone is having more fun together, and the kid is attending to the activity for the entire time. In other words, sometimes that problem is what the kiddo is being expected to attend to and who is doing the expecting.

I have, unfortunately, worked with many children who were significantly abused or neglected at a very young age (usually under 12 months) and have been removed from the situation and placed in foster care or some other similar arrangement. This children can initially present with symptoms of what looks like ASD- not responding to social stimuli, poor language, limited functional/pretend play, over-reliance on routines/schedules, strong sensory over-reactions. However, given a few months in a caring and nurturing environment with appropriate stimulation and activity, and these children come around pretty quickly and often catch up with where they are supposed to be. Again- these are really young kids. I'd imagine that the effects of such trauma on older children with better memory, language, etc. would be different and potentially longer lasting.

 

[futureapppsy2]

I have, unfortunately, worked with many children who were significantly abused or neglected at a very young age (usually under 12 months) and have been removed from the situation and placed in foster care or some other similar arrangement. This children can initially present with symptoms of what looks like ASD- not responding to social stimuli, poor language, limited functional/pretend play, over-reliance on routines/schedules, strong sensory over-reactions. However, given a few months in a caring and nurturing environment with appropriate stimulation and activity, and these children come around pretty quickly and often catch up with where they are supposed to be. Again- these are really young kids. I'd imagine that the effects of such trauma on older children with better memory, language, etc. would be different and potentially longer lasting.

Yep, this has been my experience as well. And I don't know if it was just our patient population, but I'd say that easily half, maybe more, of our kids (3-17) who came for ASD evaluations had significant abuse/neglect (often with substantiated CPS involvement). So, we did do a lot of looking at how much something was trauma-related behavior v. ASD.

 

[romanticscience]

View attachment Pages from adhd_in_adultsfinal_guidelines_june2017.pdf
This has helped me with differential diagnosis.

 

[bluecolourskies]

Yep, this has been my experience as well. And I don't know if it was just our patient population, but I'd say that easily half, maybe more, of our kids (3-17) who came for ASD evaluations had significant abuse/neglect (often with substantiated CPS involvement). So, we did do a lot of looking at how much something was trauma-related behavior v. ASD.

This is exactly what I’m struggling with too!! Any resources/readings so I can learn about this specific issue? (besides consulting with my colleagues!)

 

[bluecolourskies]

View attachment 374229
This has helped me with differential diagnosis.

thank you!

 

[smalltownpsych]

What I am seeing for referrals with that type of question is that they are usually related to therapist feeling in over their head or being stuck for some reason. IQ of 70 with bad life experiences is going to be hard to help and most of what they are going to need is a safe, supportive, and understanding environment. Seeking diagnostic clarity is part of the problem because it perpetuates the belief that a simple solution could “fix” this kid. What these kids need is not available so it don’t matter what the diagnosis is or what pill or trauma treatment is thrown at them and they will just get worse and they will be the problem not the system. I could help a kid like this but it would cost a lot of money and it would take years because they aren’t going to get better and not need a lot of support because life will continue to get more challenging.

 

[PikminOC]

What I am seeing for referrals with that type of question is that they are usually related to therapist feeling in over their head or being stuck for some reason. IQ of 70 with bad life experiences is going to be hard to help and most of what they are going to need is a safe, supportive, and understanding environment. Seeking diagnostic clarity is part of the problem because it perpetuates the belief that a simple solution could “fix” this kid. What these kids need is not available so it don’t matter what the diagnosis is or what pill or trauma treatment is thrown at them and they will just get worse and they will be the problem not the system. I could help a kid like this but it would cost a lot of money and it would take years because they aren’t going to get better and not need a lot of support because life will continue to get more challenging.

I see therapists in the community that at "neurodiversity affirming" and agree with everything their clients say and then want confirmation of what the client says for meds, or some other gain. Then they look like the good guy when the other person says they don't have it..

 

[AcronymAllergy]

I see therapists in the community that at "neurodiversity affirming" and agree with everything their clients say and then want confirmation of what the client says for meds, or some other gain. Then they look like the good guy when the other person says they don't have it..

Yep, and this happens in a whooooooole lot of areas other than neurodiversity, although not always necessarily with the meds part. See: mTBI, PTSD, ADHD, anything related to disability evaluations, etc.

 

[borne_before]

View attachment 374229
This has helped me with differential diagnosis.

That differential diagnosis is bull**** from the very first page - there is no such thing as specific intellectual disability. It then conflates them with well delineated LEARNING disabilities like dyslexia.

To conflate dyslexia with an intellectual problem is daft as heck.

Use it for TP.

 

[borne_before]

Hello, the primary focus of my training and work has been with forensic assessment. I am fairly confident in my skills for performing differential diagnosis with psychosis based disorders vs substance use vs personality disorders vs something else.

However, I have since moved on to working more with the general population (still conducting assessment) with both kids and adults, and I find that I am not as familiar with the autism vs adhd vs trauma presentations. And then also ODD with kids in addition to the above. To note, the assessments referral questions are more like “what else are we missing in terms of guiding treatment” vs a specific evaluation to rule out autism, adhd, etc. If I do suspect ASD or ADHD, I typically say that this is beyond the referral question and we need to refer out to someone for these specific diagnoses.

This is awesome! Saying "I dunno... let me see someone who does" is great thing to do.

Sometimes the clients come in with these diagnoses already, but I need to be able to tease out if there is something else or more going on. Many do have trauma, IQ is usually between 70-80.

My only thought about this is tangental - but look at parent IQ guesstimate, the impact of substance exposure, etc and you'll find that many of these borderline cases are really just gonna meet diagnostic criteria for mild intellectual disability once their IQ settles down and stabilizes.

That being said, I did do a year long practicum way back in grad school, in a center that did autism/ADHD/LD evals with kids so it’s not like I am completely unfamiliar, but this was a long time ago.

My advice would be to focus on autism - do an ADOS-2 training. That'll be eye opening for you. Spend some time around autistic kids.

Because this always seems to come up- I frequently consult with my wonderful colleagues and supervisor but would like to build up my competency in these areas.

Sorry if any of that is unclear!

I like many above see a fair amount of abuse and neurodevelopmental concerns. Like the worst abuse to the worst neglect (like no occipital cleft because they were in a car seat in a closet as their skull formed up). Once in a nurturing environment, they make strides.

I think there is also a tendency in grad school to think that "i'll always have the answer - there is only one diagnosis". But that is a trap. Many times your job is to figure out the most likely diagnoses. But even that is a trap - because in my state you can give at-risk for several diagnoses that'll bring the early intervention calvary running.

Once you spend more time doing this, it begins to make more sense. There is no single test for a lot of this stuff.

But the real answer is that there are neurodevelopmental disabilities, bad things that happen to kids that they have no control over, and genetic stuff going.

 

[aim-agm]

I often find myself explaining to parents that, at that age, sustained play is usually a) pretend or imaginative; and b) language based. If the kid doesn't yet display pretend/imaginative play (due to ASD or other delay in development) and doesn't speak, there is little to "ground" them in sustained play. With the social attributions and language to go with it, toys are just a collection of different physical properties. Once you figure out how it looks, feels, moves, sounds, tastes, etc., you can quickly move on to the next one. This may look like poor attention (ADHD), but it is more a case of too much attention on the non-social parts of the world.

I'm curious, is this related to the development of restricted, excessive interests in ASD? That is, do they come across something they can experience abstract properties of rather than just physical ones which makes it capable of sustaining their interest in that thing, and then all their interest attaches to that thing because it has nowhere else to be attached to?

 

[borne_before]

I'm curious, is this related to the development of restricted, excessive interests in ASD? That is, do they come across something they can experience abstract properties of rather than just physical ones which makes it capable of sustaining their interest in that thing, and then all their interest attaches to that thing because it has nowhere else to be attached to?

The OG behaviorists would ask: does it matter?

Personally, I suspect that they probably just like how spinning wheels or dangling strings look.

I think clincalaba is harking on the civilizing impact of language and how it enables abstraction. I wonder how aphasia patients who have regained the ability to verbalize would answer that question.

 

[borne_before]

I'm curious, is this related to the development of restricted, excessive interests in ASD? That is, do they come across something they can experience abstract properties of rather than just physical ones which makes it capable of sustaining their interest in that thing, and then all their interest attaches to that thing because it has nowhere else to be attached to?

Also - I wonder if the answer lies in change in play once interventions get language online. Does an aac or development of representational language substantially change quality of play? Is that when you start seeing the same scenes being played over and over again?

 

[ClinicalABA]

I'm curious, is this related to the development of restricted, excessive interests in ASD? That is, do they come across something they can experience abstract properties of rather than just physical ones which makes it capable of sustaining their interest in that thing, and then all their interest attaches to that thing because it has nowhere else to be attached to?

The phrase "attaches to" can be a bit loaded in a psychological sense! I thinks it's more of an issue of repertoire, than it is "attachment." Remember- I'm talking about toddlers here- 2-3 years old. We only expect pretend play to be emerging around 2 years old. The child does not yet know how to use language in play, and thus is somewhat restricted to non-language-based (e.g., a focus on the stuff for what it is, rather than what it represents). This leads to relatively quick movement between objects or to relatively less brief attention to paid to caregiver directed language-based play. This in turn is interpreted as a deficit in attention, when it's actually a deficit in language and pretend play skills.

Ultimately, as @borne_before alluded to, it's an observation that these children play less with toys and activities that lend themselves to extended, functional, and pretend play. If, through teaching or maturation, the child's language improves and we then see more "attentive" play, it stops looking like an attention issue.

 

[borne_before]

The phrase "attaches to" can be a bit loaded in a psychological sense! I thinks it's more of an issue of repertoire, than it is "attachment." Remember- I'm talking about toddlers here- 2-3 years old. We only expect pretend play to be emerging around 2 years old. The child does not yet know how to use language in play, and thus is somewhat restricted to non-language-based (e.g., a focus on the stuff for what it is, rather than what it represents). This leads to relatively quick movement between objects or to relatively less brief attention to paid to caregiver directed language-based play. This in turn is interpreted as a deficit in attention, when it's actually a deficit in language and pretend play skills.

Ultimately, as @borne_before alluded to, it's an observation that these children play less with toys and activities that lend themselves to extended, functional, and pretend play. If, through teaching or maturation, the child's language improves and we then see more "attentive" play, it stops looking like an attention issue.

Dude, I am super annoyed by your insight. and my ignorance about it. Where did you learn about the link between language and play. It had never crossed my mind.

 

[ClinicalABA]

Dude, I am super annoyed by your insight. and my ignorance about it. Where did you learn about the link between language and play. It had never crossed my mind.

I've been doing this awhile, and it's literally all I do clinically. In the last year, i've capped my new referral age limit at 34 months. When you really focus on doing one thing, you can really focus on learning as much as you can about that thing. In my case, it's 12-36 year old development- language, play, cognitive skills, motor skills, and manifestations of ASD. Trade off is that it can be VERY repetitive but I've had enough crazy unpredictable jobs that I like knowing- for the most part- what's walking through my door every morning. As to play and language, I did a workshop a few years ago at ABAI with some co-workers (including speech therapist) on teaching language through play, so I did a lot of research on play development, language development, verbal behavior, and the interface between all of it.

I think there are some cohort effects, too. I am of a generation where my mind is still blown that I can do a literature search from wherever I am and- most mind blowingly- get the articles immediately. When I encounter something new or interesting when working with a kiddo, I jot it down and do a lit search later that day/week, being sure to look at not only psych or ABA journals, but speech, OT, social work, etc.

(Beware- old man story coming!) Back in the dark ages when I was in graduate school, you actually had to go to the library to do a literature search, then you had to get the hard copy of the journal and make a photocopy of the article you wanted. At my school (UMass Amherst), the library was a 26 story monolith, with all the database computers and photocopiers on the basement level, and the psych journals on floors 18 for the current year and 21-23 for previous years (when I was an undergrad there, you could actually smoke cigarettes on the 26th floor with a wonderful 360 degree, 4 state view on a clear day, but that's another story!). Elevators only ran from basement to 16, and then from 16 to 26. So, you would have to do your lit search, print out the references (dot matrix!!), take the elevator to the 16th floor, get off and take another elevator to the 18th-23rd floor, find as many journals as you could carry (and typically a whole year or two's worth would be bound togethers, so they were heavy), repeat the whole elevator transfer process back down to the basement to the photo copiers. There, you would need to wait in line for your turn at the copier, put in your "copy card" that you loaded with credits from a different machine (using this paper stuff called "cash"), and copy each freaking page, one at a time, until you had everything you needed. Fortunately, you could then just leave the journals in the basement, and some poor shmuck on work study would have to schlepp them all back up 20 floors and refile them. Inevitably, you would leave your freshly loaded copy card (with up to $36 in 2023 dollars worth of credits) in the machine when you left. we did this at least twice a week!

TLDR- it's so freaking easy and cheap to do a lit search and get the articles, that there really is no excuse for not being up on what's going on. Pay attention to what you don't understand, and try to understand it better by the next week. You'll better serve your clients, and you'll just be plain better at your job.

 

[ClinicalABA]

Dude, I am super annoyed by your insight. and my ignorance about it. Where did you learn about the link between language and play. It had never crossed my mind.

Also- when encountering something that others are positing as being a "behavioral excess" (i.e., the kiddo is doing something unusual, maladaptive, extreme, etc.) I've trained myself to always ask myself "what should they be doing instead?" With little kids and ASD, the issue is not that they are engaging in repetitive or routinized play, it's that they aren't engaging in pretend/imaginative story-based play. The important question isn't "why are they doing all this 'unusual' stuff", but rather "why aren't they doing all the other more 'usual' stuff." The latter question leads to more constructive, positive programming and goals.

 

[Pragma]

(Beware- old man story coming!) Back in the dark ages when I was in graduate school, you actually had to go to the library to do a literature search, then you had to get the hard copy of the journal and make a photocopy of the article you wanted. At my school (UMass Amherst), the library was a 26 story monolith, with all the database computers and photocopiers on the basement level, and the psych journals on floors 18 for the current year and 21-23 for previous years (when I was an undergrad there, you could actually smoke cigarettes on the 26th floor with a wonderful 360 degree, 4 state view on a clear day, but that's another story!). Elevators only ran from basement to 16, and then from 16 to 26. So, you would have to do your lit search, print out the references (dot matrix!!), take the elevator to the 16th floor, get off and take another elevator to the 18th-23rd floor, find as many journals as you could carry (and typically a whole year or two's worth would be bound togethers, so they were heavy), repeat the whole elevator transfer process back down to the basement to the photo copiers. There, you would need to wait in line for your turn at the copier, put in your "copy card" that you loaded with credits from a different machine (using this paper stuff called "cash"), and copy each freaking page, one at a time, until you had everything you needed. Fortunately, you could then just leave the journals in the basement, and some poor shmuck on work study would have to schlepp them all back up 20 floors and refile them. Inevitably, you would leave your freshly loaded copy card (with up to $36 in 2023 dollars worth of credits) in the machine when you left. we did this at least twice a week!

TLDR- it's so freaking easy and cheap to do a lit search and get the articles, that there really is no excuse for not being up on what's going on. Pay attention to what you don't understand, and try to understand it better by the next week. You'll better serve your clients, and you'll just be plain better at your job.

It is sad that these are old man stories, but PhD used to mean "photocopying degree" for all of the course materials they made you go copy yourself the first week. I could troubleshoot all sorts of Lexmark problems (at a doctoral level by completion).

Also - YES to the library stuff. In my case it was a large state university with libraries across their metropolitan campus. I'd take buses to 6 different libraries to go photocopy the hard copy (and on occasion, used the microfiche machines for older stuff). There is something to putting in effort to obtain information that makes you encode it better or contemplate it more.

 

[borne_before]

I've been doing this awhile, and it's literally all I do clinically. In the last year, i've capped my new referral age limit at 34 months. When you really focus on doing one thing, you can really focus on learning as much as you can about that thing. In my case, it's 12-36 year old development- language, play, cognitive skills, motor skills, and manifestations of ASD. Trade off is that it can be VERY repetitive but I've had enough crazy unpredictable jobs that I like knowing- for the most part- what's walking through my door every morning. As to play and language, I did a workshop a few years ago at ABAI with some co-workers (including speech therapist) on teaching language through play, so I did a lot of research on play development, language development, verbal behavior, and the interface between all of it.

I think there are some cohort effects, too. I am of a generation where my mind is still blown that I can do a literature search from wherever I am and- most mind blowingly- get the articles immediately. When I encounter something new or interesting when working with a kiddo, I jot it down and do a lit search later that day/week, being sure to look at not only psych or ABA journals, but speech, OT, social work, etc.

(Beware- old man story coming!) Back in the dark ages when I was in graduate school, you actually had to go to the library to do a literature search, then you had to get the hard copy of the journal and make a photocopy of the article you wanted. At my school (UMass Amherst), the library was a 26 story monolith, with all the database computers and photocopiers on the basement level, and the psych journals on floors 18 for the current year and 21-23 for previous years (when I was an undergrad there, you could actually smoke cigarettes on the 26th floor with a wonderful 360 degree, 4 state view on a clear day, but that's another story!). Elevators only ran from basement to 16, and then from 16 to 26. So, you would have to do your lit search, print out the references (dot matrix!!), take the elevator to the 16th floor, get off and take another elevator to the 18th-23rd floor, find as many journals as you could carry (and typically a whole year or two's worth would be bound togethers, so they were heavy), repeat the whole elevator transfer process back down to the basement to the photo copiers. There, you would need to wait in line for your turn at the copier, put in your "copy card" that you loaded with credits from a different machine (using this paper stuff called "cash"), and copy each freaking page, one at a time, until you had everything you needed. Fortunately, you could then just leave the journals in the basement, and some poor shmuck on work study would have to schlepp them all back up 20 floors and refile them. Inevitably, you would leave your freshly loaded copy card (with up to $36 in 2023 dollars worth of credits) in the machine when you left. we did this at least twice a week!

TLDR- it's so freaking easy and cheap to do a lit search and get the articles, that there really is no excuse for not being up on what's going on. Pay attention to what you don't understand, and try to understand it better by the next week. You'll better serve your clients, and you'll just be plain better at your job.

Also- when encountering something that others are positing as being a "behavioral excess" (i.e., the kiddo is doing something unusual, maladaptive, extreme, etc.) I've trained myself to always ask myself "what should they be doing instead?" With little kids and ASD, the issue is not that they are engaging in repetitive or routinized play, it's that they aren't engaging in pretend/imaginative story-based play. The important question isn't "why are they doing all this 'unusual' stuff", but rather "why aren't they doing all the other more 'usual' stuff." The latter question leads to more constructive, positive programming and goals.

I get that experience pays off. But damn. I've only been licensed 5 years. But, I think I am going to do some more of that ABAI training. Makes total sense.

I love how the second point leads more clearly to potential treatment/recommendations.

 

[ClinicalABA]

I get that experience pays off. But damn. I've only been licensed 5 years. But, I think I am going to do some more of that ABAI training. Makes total sense.

I love how the second point leads more clearly to potential treatment/recommendations.

ABAI is the Association for Behavior Analysis International- basically the major org/conference for ABA. They actually don't really do a lot of stuff focusing on assessment and development. Our workshop was a bit of an outlier. Hit me up and I'll share my materials or even set up a zoom to review the language and play stuff.

 

[Fan_of_Meehl]

It is sad that these are old man stories, but PhD used to mean "photocopying degree" for all of the course materials they made you go copy yourself the first week. I could troubleshoot all sorts of Lexmark problems (at a doctoral level by completion).

Also - YES to the library stuff. In my case it was a large state university with libraries across their metropolitan campus. I'd take buses to 6 different libraries to go photocopy the hard copy (and on occasion, used the microfiche machines for older stuff). There is something to putting in effort to obtain information that makes you encode it better or contemplate it more.

Fellow grad students and I used to joke about getting a 'copy tan' due to the light of the copier as we hand photocopied page after page of journal articles or book chapters. My 'mental map' of the 2nd floor of the university library where I spent all those nights photocopying, reading, and wandering the 'stacks' of professional journals is more solid and elaborated to this day than the mental map of my first apartment itself.

 

[smalltownpsych]

Also- when encountering something that others are positing as being a "behavioral excess" (i.e., the kiddo is doing something unusual, maladaptive, extreme, etc.) I've trained myself to always ask myself "what should they be doing instead?" With little kids and ASD, the issue is not that they are engaging in repetitive or routinized play, it's that they aren't engaging in pretend/imaginative story-based play. The important question isn't "why are they doing all this 'unusual' stuff", but rather "why aren't they doing all the other more 'usual' stuff." The latter question leads to more constructive, positive programming and goals.

100% agree with this. So much poor treatment focuses on trying to stop unwanted behaviors on so many levels and it starts with the kids and keeps on going. It leads to punitive “treatments” and as any psychologist or even undergrad major in psychology for that matter should know, punishment is only effective in the short term and often results in development of more maladaptive behaviors such as lying to avoid punishment or learned helplessness when all the kid gets is punished. Some punishment makes a little bit of sense, but effective and lasting behavior change is about reinforcement. Venting a little because I have some patients currently who have spent years being punished for doing “bad things” in the name of treatment and they have just gotten worse and now I have to try to undo all of that.

 

[Fan_of_Meehl]

100% agree with this. So much poor treatment focuses on trying to stop unwanted behaviors on so many levels and it starts with the kids and keeps on going. It leads to punitive “treatments” and as any psychologist or even undergrad major in psychology for that matter should know, punishment is only effective in the short term and often results in development of more maladaptive behaviors such as lying to avoid punishment or learned helplessness when all the kid gets is punished. Some punishment makes a little bit of sense, but effective and lasting behavior change is about reinforcement. Venting a little because I have some patients currently who have spent years being punished for doing “bad things” in the name of treatment and they have just gotten worse and now I have to try to undo all of that.

The 'matching law' governs so much of human behavioral choice that it is almost invisible due to its ubiquity and subtlety of operation.

 

[smalltownpsych]

The 'matching law' governs so much of human behavioral choice that it is almost invisible due to its ubiquity and subtlety of operation.

Not completely sure how you mean this applies. I am always trying to understand this stuff because part of the fallacy in our field is that we just need to find better people and yet the same patterns keep happening regardless of the people involved and since I am creating a system, I believe that the more I understand the psychological principles involved the better my chance at having a healthier or more functional system.

 

[Fan_of_Meehl]

Not completely sure how you mean this applies. I am always trying to understand this stuff because part of the fallacy in our field is that we just need to find better people and yet the same patterns keep happening regardless of the people involved and since I am creating a system, I believe that the more I understand the psychological principles involved the better my chance at having a healthier or more functional system.

It's a gross oversimplification (the full explanation, as I understand it, is a bit mathematical) but...

Basically, differential rates of reinforcement for different operants (in a particular environment) explain differential rates of the organism emitting those operants.

Practical application: kid is engaging in self-injury for attention (but there is no other means of getting attention provided by the environment), increase rate of reinforcement of some other operant (vocalization for attention), get less self-injury and more vocalization for attention.

Again, likely a gross oversimplification (and, of course, you have to train the kid to emit the new behavior (vocalization)). I'm sure that there is a way that the matching law is different somehow (technically) than the principle of differential reinforcement...but it's been years since I was working in applied behavior analysis contexts.

 

[smalltownpsych]

It's a gross oversimplification (the full explanation, as I understand it, is a bit mathematical) but...

Basically, differential rates of reinforcement for different operants (in a particular environment) explain differential rates of the organism emitting those operants.

Practical application: kid is engaging in self-injury for attention (but there is no other means of getting attention provided by the environment), increase rate of reinforcement of some other operant (vocalization for attention), get less self-injury and more vocalization for attention.

Again, likely a gross oversimplification (and, of course, you have to train the kid to emit the new behavior (vocalization)). I'm sure that there is a way that the matching law is different somehow (technically) than the principle of differential reinforcement...but it's been years since I was working in applied behavior analysis contexts.

Ahhh. So if there are less alternative reinforcers to “compete” in the equation, then there will be increased maladaptive behaviors get this need met. Yup. Math is unarguable and the math for behavioral principles is pretty straightforward.

 

[ClinicalABA]

Ahhh. So if there are less alternative reinforcers to “compete” in the equation, then there will be increased maladaptive behaviors get this need met. Yup. Math is unarguable and the math for behavioral principles is pretty straightforward.

In general, yes. There are of course other variables at play (biases towards certain behaviors; sensitivity to changes in reinforcement ratios) that, when accounted for make for better prediction than the simplified matching law equation (the one in my signature). The simplified equation is merely adequate, at best, in predicting behaviors when there are, for example, concurrent schedules of reinforcement in place. The "generalized matching law" that accounts for some of these other variables is more complex: log(R1/R2)=log(b)+s x log(Rf1/Rf2), where b=bias and s=sensitivy.

In the case of ASD and language/social-based play, the important thing is what @Fan_of_Meehl alludes to in the parenthetical statement about teaching the new behavior. Since language/social play is not in the child's repertoire, the rate of that behavior (i.e. R2) and the reinforcement for that behavior (Rf2) both equal zero. Plugging that back into the generalized matching law equation you have a couple of fractions with zero in the denominator, which is is a no-no. In this case, it's not an issue that language/social play isn't being reinforced enough relative to how other types of play are reinforced, but rather it doesn't happen, so it can't and hasn't been reinforced at all.

 

[Ollie123]

100% agree with this. So much poor treatment focuses on trying to stop unwanted behaviors on so many levels and it starts with the kids and keeps on going. It leads to punitive “treatments” and as any psychologist or even undergrad major in psychology for that matter should know, punishment is only effective in the short term and often results in development of more maladaptive behaviors such as lying to avoid punishment or learned helplessness when all the kid gets is punished. Some punishment makes a little bit of sense, but effective and lasting behavior change is about reinforcement. Venting a little because I have some patients currently who have spent years being punished for doing “bad things” in the name of treatment and they have just gotten worse and now I have to try to undo all of that.

Sorry for the derail but can't help myself here since I believe you are interested in SUD as well.

Lots of interesting work starting to come out on the role of competing/alternative reinforcers in addiction. Surprise, surprise, people may be more likely to use substances if they don't have many other sources of reinforcement in their lives. People who do have alternative sources of reinforcement in their lives are more likely to succeed in treatment. And psychological/psychiatric traditional treatment approaches for addiction is focused almost exclusively on "Stop drinking/doing drugs." Not "How do I build an enjoyable and meaningful substance-free lifestyle." Also, our entire sociopolitical system is basically designed to make it harder for people to build an enjoyable/meaningful substance-free lifestyle once they enter the criminal justice system, but I digress....

Obviously very different context from ASD kiddos, but the broader issue very much persists into adult tx.

 

[bluecolourskies]

Sorry for the derail but can't help myself here since I believe you are interested in SUD as well.

Lots of interesting work starting to come out on the role of competing/alternative reinforcers in addiction. Surprise, surprise, people may be more likely to use substances if they don't have many other sources of reinforcement in their lives. People who do have alternative sources of reinforcement in their lives are more likely to succeed in treatment. And psychological/psychiatric traditional treatment approaches for addiction is focused almost exclusively on "Stop drinking/doing drugs." Not "How do I build an enjoyable and meaningful substance-free lifestyle." Also, our entire sociopolitical system is basically designed to make it harder for people to build an enjoyable/meaningful substance-free lifestyle once they enter the criminal justice system, but I digress....

Obviously very different context from ASD kiddos, but the broader issue very much persists into adult tx.

I am also interested in learning more about this in the context of forensic/correctional work, which that system is also largely punitive.

 

[smalltownpsych]

Sorry for the derail but can't help myself here since I believe you are interested in SUD as well.

Lots of interesting work starting to come out on the role of competing/alternative reinforcers in addiction. Surprise, surprise, people may be more likely to use substances if they don't have many other sources of reinforcement in their lives. People who do have alternative sources of reinforcement in their lives are more likely to succeed in treatment. And psychological/psychiatric traditional treatment approaches for addiction is focused almost exclusively on "Stop drinking/doing drugs." Not "How do I build an enjoyable and meaningful substance-free lifestyle." Also, our entire sociopolitical system is basically designed to make it harder for people to build an enjoyable/meaningful substance-free lifestyle once they enter the criminal justice system, but I digress....

Obviously very different context from ASD kiddos, but the broader issue very much persists into adult tx.

Good topic and I like the slight derail into behavioral principles. I’m still wondering if I used unarguable correctly or I should have used inarguable. lol
I do really think that too many in this field neglect the power and importance of behavioral principles when formulating interventions and even when they do they tend to oversimplify and misunderstand. One of the reasons I am such a fan of Linehan is that she emphasizes behaviorism in her model.
As you state much different populations, my thought is that we rely on subtle social and interpersonal reinforcers with most other populations and these are less effective with the ASD population so we need to focus on other more concrete reinforcers. I think the mistake clinicians make is not seeing the ubiquity of these principles and conceptualize something simple vs complex as two different things. An analogy is when people say that animals can’t communicate when what they mean is that they don’t have complex verbal language.

 

[ClinicalABA]

Sorry for the derail but can't help myself here since I believe you are interested in SUD as well.

Lots of interesting work starting to come out on the role of competing/alternative reinforcers in addiction. Surprise, surprise, people may be more likely to use substances if they don't have many other sources of reinforcement in their lives. People who do have alternative sources of reinforcement in their lives are more likely to succeed in treatment. And psychological/psychiatric traditional treatment approaches for addiction is focused almost exclusively on "Stop drinking/doing drugs." Not "How do I build an enjoyable and meaningful substance-free lifestyle." Also, our entire sociopolitical system is basically designed to make it harder for people to build an enjoyable/meaningful substance-free lifestyle once they enter the criminal justice system, but I digress....

Obviously very different context from ASD kiddos, but the broader issue very much persists into adult tx.

It's almost like there are some universal rules of human behavior that apply to multiple different behaviors and concepts. If only there was a discipline focused on identifying those rules and designing effective interventions for when things don't seem to be going well! If practitioners of said discipline could also shift their focus from one specific area- even though that is where the money is- and learn to communicate better with other disciplines who might have different training/beliefs/etc., imagine what a world it would be?

 

[clausewitz2]

It's almost like there are some universal rules of human behavior that apply to multiple different behaviors and concepts. If only there was a discipline focused on identifying those rules and designing effective interventions for when things don't seem to be going well! If practitioners of said discipline could also shift their focus from one specific area- even though that is where the money is- and learn to communicate better with other disciplines who might have different training/beliefs/etc., imagine what a world it would be?

Yeah it'd be so great if there was a field really coming to grips with people's psyches and trying to use what it learned about their psyches to better understand their behavior, motivations, and thought processes. It could also totally use that knowledge about their psyches to maybe help them live better or more fulfilling lives as a result of better functioning of their psyches.

I think it could be called ... people-thinking-and-doing-stuff studies.

 

[cara susanna]

Yeah it'd be so great if there was a field really coming to grips with people's psyches and trying to use what it learned about their psyches to better understand their behavior, motivations, and thought processes. It could also totally use that knowledge about their psyches to maybe help them live better or more fulfilling lives as a result of better functioning of their psyches.

I think it could be called ... people-thinking-and-doing-stuff studies.

I think it was called The Bus That Couldn't Slow Down.

 

[Fan_of_Meehl]

I see therapists in the community that at "neurodiversity affirming" and agree with everything their clients say and then want confirmation of what the client says for meds, or some other gain. Then they look like the good guy when the other person says they don't have it..

I have always found clinicians who lie to their patients in an effort to 'be good to them' or to 'advocate for them' (at least this is what they claim publicly) don't actually care for these clients or want them to live satisfying lives. Collusive lying between patient and 'professional' is becoming so common in mental health practice as to be an outright epidemic these days.

Self-deception is at the heart of mental illness and feeding (or failing to carefully question) that narrative as a mental health provider strikes me as just as ethical as the theoretical endocrinologist who would prescribe a half a dozen glazed doughnuts t.i.d. for all of his Type II diabetic patients because he wants to 'be good to them' or to 'advocate for them (their 'preferences?')'

 

[smalltownpsych]

I have always found clinicians who lie to their patients in an effort to 'be good to them' or to 'advocate for them' (at least this is what they claim publicly) don't actually care for these clients or want them to live satisfying lives. Collusive lying between patient and 'professional' is becoming so common in mental health practice as to be an outright epidemic these days.

Self-deception is at the heart of mental illness and feeding (or failing to carefully question) that narrative as a mental health provider strikes me as just as ethical as the theoretical endocrinologist who would prescribe a half a dozen glazed doughnuts t.i.d. for all of his Type II diabetic patients because he wants to 'be good to them' or to 'advocate for them (their 'preferences?')'

Being honest with our patients and sharing our observations, perspective, and knowledge in a non-judgmental way and in a way that maximizes patients motivation to to change in a way that benefits them is at the heart of what we do. I am never being good to my patients or advocating for them. I help them to be good to and advocate for themselves. As a I reread that it makes it sound like I’m not even nice to them. lol. Truth is that I am a little more like Rogers interpersonally than Ellis so am definitely “nice” and empathic but I also am warmly and empathically responding to how painful it is to continue to make crappy life choices and want someone else to fix it. 😉

 

[PikminOC]

I have always found clinicians who lie to their patients in an effort to 'be good to them' or to 'advocate for them' (at least this is what they claim publicly) don't actually care for these clients or want them to live satisfying lives. Collusive lying between patient and 'professional' is becoming so common in mental health practice as to be an outright epidemic these days.

Self-deception is at the heart of mental illness and feeding (or failing to carefully question) that narrative as a mental health provider strikes me as just as ethical as the theoretical endocrinologist who would prescribe a half a dozen glazed doughnuts t.i.d. for all of his Type II diabetic patients because he wants to 'be good to them' or to 'advocate for them (their 'preferences?')'

💯

 

[futureapppsy2]

Sorry for the derail but can't help myself here since I believe you are interested in SUD as well.

Lots of interesting work starting to come out on the role of competing/alternative reinforcers in addiction. Surprise, surprise, people may be more likely to use substances if they don't have many other sources of reinforcement in their lives. People who do have alternative sources of reinforcement in their lives are more likely to succeed in treatment. And psychological/psychiatric traditional treatment approaches for addiction is focused almost exclusively on "Stop drinking/doing drugs." Not "How do I build an enjoyable and meaningful substance-free lifestyle." Also, our entire sociopolitical system is basically designed to make it harder for people to build an enjoyable/meaningful substance-free lifestyle once they enter the criminal justice system, but I digress....

Obviously very different context from ASD kiddos, but the broader issue very much persists into adult tx.

So, when I teach group counseling, I actually teach the whole challenging behavior unit as behavior analysis and have them apply things like FBA, differential reinforcement, etc, to challenging behavior that occurs in groups that they would be leading. Truly, the principles of behavior really do apply to everything, and its a shame that they are cast as something that only applies to animals and ASD/DD populations. (I think this is one of the reasons for the hatred of ABA among a lot of autistic adults--because it's seen as a very dehumanizing thing, but really, it's just the essence of existing. Everyone is trying to get their needs met in the best way they can, and a lot of times, people engage in "bad" behavior because they literally don't have another way of getting that need effectively met). I like to show this video of Pat Friman to illustrate:

@ClinicalABA , you can take the behavior analyst out of an ABA program, but you can't take the ABA out of the behavior analyst!

 

[ClinicalABA]

@ClinicalABA[/USER] , you can take the behavior analyst out of an ABA program, but you can't take the ABA out of the behavior analyst!

I have always found Friman to be a thoughtful presenter- both in the sense that he puts a lot of thought into what he says, and also care deeply about the topics and individuals he is talking about. Having seen him at many regional and national conferences, it's always stood out to me that he identifies as a clinical psychologist, rather than as a behavior analyst, though his ABA cred is second-to-none (editor of JABA; president of ABAI). He's talked about the distinction being a bit spurious, and there certainly has been more focus at ABAI and regional conferences on things other than ASD, as well as on the need to be wary of becoming technicians rather than clinicians. I've also appreciated the recognition of the need to be less isolative and pedantic, as well as to "divorce" the field from some of the more questionable practices (e.g., contingent skin shock).

Unfortunately for ABA, one of it's greatest achievements may also be one of it's greatest limitations- autism insurance mandates. Through a tremendous amount of advocacy, lobbying, and determination most states have gone from no-coverage for ABA services to mandated insurance coverage- often with no caps- delivered by a relatively newly credentialed/licensed clinical entity (i.e., BCBA/LABA). This is all within recent memory (in many cases less than a decade). Psychology could learn something from this. In a matter of a few years, ABA has gone from something you hoped a kiddo MIGHT get at school, to something that venture capitalists are now targeting (as much as that sucks and WILL NOT END WELL).

However, the flip side of that is that- at the practitioner level- the field has focused almost exclusively on masters level credentialing/licensure, with training and reimbursement models focused primarily (if not almost exclusively) on ASD. As whole new academic ABA divisions/departments have emerged, ABA has become even more distanced from clinical pych, and vice-versa. Even recent trends to contrary (e.g., acceptance and commitment therapy) have- imho- only been widely accepted by the ill-informed masses of primarily MA therapists because they are not easily identifiable as having roots in ABA. Call that stuff "Relational-Frame-Based Functional Analytic Therapy" and the crystal worshipping LMHCs at my local CMHC who haven't read an outcome study in their lives are not touching it.

 

[futureapppsy2]

I have always found Friman to be a thoughtful presenter- both in the sense that he puts a lot of thought into what he says, and also care deeply about the topics and individuals he is talking about. Having seen him at many regional and national conferences, it's always stood out to me that he identifies as a clinical psychologist, rather than as a behavior analyst, though his ABA cred is second-to-none (editor of JABA; president of ABAI). He's talked about the distinction being a bit spurious, and there certainly has been more focus at ABAI and regional conferences on things other than ASD, as well as on the need to be wary of becoming technicians rather than clinicians. I've also appreciated the recognition of the need to be less isolative and pedantic, as well as to "divorce" the field from some of the more questionable practices (e.g., contingent skin shock).

Unfortunately for ABA, one of it's greatest achievements may also be one of it's greatest limitations- autism insurance mandates. Through a tremendous amount of advocacy, lobbying, and determination most states have gone from no-coverage for ABA services to mandated insurance coverage- often with no caps- delivered by a relatively newly credentialed/licensed clinical entity (i.e., BCBA/LABA). This is all within recent memory (in many cases less than a decade). Psychology could learn something from this. In a matter of a few years, ABA has gone from something you hoped a kiddo MIGHT get at school, to something that venture capitalists are now targeting (as much as that sucks and WILL NOT END WELL).

However, the flip side of that is that- at the practitioner level- the field has focused almost exclusively on masters level credentialing/licensure, with training and reimbursement models focused primarily (if not almost exclusively) on ASD. As whole new academic ABA divisions/departments have emerged, ABA has become even more distanced from clinical pych, and vice-versa. Even recent trends to contrary (e.g., acceptance and commitment therapy) have- imho- only been widely accepted by the ill-informed masses of primarily MA therapists because they are not easily identifiable as having roots in ABA. Call that stuff "Relational-Frame-Based Functional Analytic Therapy" and the crystal worshipping LMHCs at my local CMHC who haven't read an outcome study in their lives are not touching it.

Yeah. I feel like ACT is in a weird place, where ABA people claim that it's pure ABA (which I don't agree with) and most people who use it don't know anything about ABA (and sometimes don't know anything about ACT, let's be real). A friend of mine was actually a co-author on a paper years ago on why psychology departments should reclaim ABA from SPED departments, but it never got accepted and then she went to an extremely teaching heavy institution.

While we're talking about ABA, I really wish that behaviorist analysts would stop trying to glom on to the neurodiversity movement without knowing anything about ableism or disability identity, culture, or pride and how you can have that and still work towards behavior change. It's like "you're trying, but I don't think you understand this at all, besides seeing the word a lot on social media."

 

[Ollie123]

I was trained in a heavily behavioral lab, taught behavior modification in graduate school and most of my research is heavily informed by contemporary behavioral theory (particularly behavioral economics). All forms of therapy have weird cults, but behaviorism (including some of the ABA crowd) cults really are....unique....relative to the others. They just seem to have glommed onto the idea that behaviorism somehow supersedes everything else and no matter what you are doing it is just behavioral therapy. Had a colleague who spent like 40 minutes explaining to me that classic cognitive therapy was really Skinnerian behaviorism for reasons that never made any effing sense and seemed to rely on reclassifying everything as behavior in nonsensical ways and making so many assumptions about unobservable things that I'm pretty sure Skinner would have actually punched him in the nose if he overheard the conversation.

Nothing was done to invite that conversation by the way. He just came into my office to have this very specific diatribe for unclear reasons and then wandered off.

 

[Fan_of_Meehl]

I was trained in a heavily behavioral lab, taught behavior modification in graduate school and most of my research is heavily informed by contemporary behavioral theory (particularly behavioral economics). All forms of therapy have weird cults, but behaviorism (including some of the ABA crowd) cults really are....unique....relative to the others. They just seem to have glommed onto the idea that behaviorism somehow supersedes everything else and no matter what you are doing it is just behavioral therapy. Had a colleague who spent like 40 minutes explaining to me that classic cognitive therapy was really Skinnerian behaviorism for reasons that never made any effing sense and seemed to rely on reclassifying everything as behavior in nonsensical ways and making so many assumptions about unobservable things that I'm pretty sure Skinner would have actually punched him in the nose if he overheard the conversation.

Nothing was done to invite that conversation by the way. He just came into my office to have this very specific diatribe for unclear reasons and then wandered off.

Just goes to show that no theoretical school is immune to religious impulse.