A Neurodivergent Deconstruction of Common Behavior Modification Practices
The purpose of therapeutic intervention is to improve quality of life by helping people develop healthier, more effective habits. Therapy can improve skill deficits, build upon strengths, and provide meaningful insights that lead to values-based life changes. The role of the helping professional is to identify needs and effective interventions to facilitate desired changes. Professionals typically employ “evidence-based practices” to ensure high quality of care for the people they purport to help. Unfortunately, meeting the standard of evidence-based does not necessarily mean these practices are safe or affirming. Currently, there is criticism from neurodiversity advocates that evidence-based interventions employed by behavior analysts within the applied behavior analysis (ABA) framework are non-affirming, harmful, and even abusive. Many behavior analysts have responded by shifting their ideology and pushing back against the antiquated practices of the “old guard,” emphasizing compassionate care, person-centered interventions, and trauma-informed care. These are meaningful steps toward an affirming therapeutic approach. However, it is also important for us to critique and deconstruct the specific interventions that cause harm to ensure our practices are neurodiversity affirming. In particular, I’d like to discuss some of the issues with operant conditioning strategies used in therapeutic interventions.
Operant conditioning is often used to teach compliance with neurotypical norms
The purpose of operant conditioning is to understand and control the process of how behavior is changed by modifying the environment. The environment may be modified through antecedent (modifying the environment) and/or consequence interventions (reinforcement and punishment). Operant conditioning is an effective strategy for modifying behavior, but the consequences of implementing interventions based in this science can be disastrous to human development and overall quality of life. While reinforcement strategies may seem benign and people often enjoy receiving rewards, it is often used to teach compliance with neurotypical expectations and standards of behavior, a form of ethnocentrism.
Preference assessment to identify highly reinforcing rewards may exacerbate dopamine pathways
Preference assessments are often used to identify preferred reinforcers/rewards that will be most effective at maintaining engagement and continued use of targeted behavior/skills. The practice seems manipulative since it systematically identifies individuals’ favorite items as part of a contingency program. There is rarely child assent, which leads to loss of autonomy, individuality, and difficulty setting boundaries and asserting needs. When dissent is not recognized and respected, individuals are taught that how they feel does not matter. Imagine if someone withheld your favorite things until you performed a targeted behavior? Imagine you had a strong aversion to this behavior, but could only obtain your favorite items through engagement?
Preference assessments often use food items, which has the potential to harm the individual’s relationship with food. The energy depletion model of eating suggests that people eat due to hunger, which is a foundational part of intuitive eating strategies (“honor your hunger”) that are often recommended by nutritionists and eating disorder specialists. The use of food reinforcers is similar to priming, which can create anticipation of food as a reward. Over time, this may initiate food-seeking behavior, which can lead to the development of overeating habits. In general, it is best practice to avoid food as a reinforcer and teach mindful and intuitive eating.
We see a similar problem arise when using screen time as a reinforcer. The research is pretty clear that excessive screen time has negative physiological and psychological effects. Screens also have the potential to develop into an addiction. Rather than using these highly rewarding objects to modify behavior, it is important for us to consider the long-term impact by modeling healthy boundaries around screen time. We should not place contingencies on screen time or food items. Rather, these items should be used in a way that does not exacerbate the dopamine reward pathways, which creates anticipatory cravings. The repeated use of these items as rewards creates an increased desire for these objects and potential for overuse.
Emphasize intrinsic motivation by building on strengths, interests, and values
Additionally, the use of external reinforcers can lead to a decrease of intrinsic motivation, overreliance on rewards for behavior change, and prompt dependence. The result is loss of autonomy. Meta-analysis has shown that contingency programs lead to a decrease in child interest in the activity that is being rewarded - this tells us that children primarily focus on earning rewards when implementing these programs. Carol Dweck proposes an alternative way to administer reinforcement through praise of effort, critical thinking, and process, which leads to increased confidence and courage. We should be specific and genuine with our praise (instead of infantilizing), which will ultimately encourage the development of intrinsic motivation. The aim is to reinforce strengths and interests one already possesses and to facilitate growth within the individual’s own values system. We must also be careful not to administer excessive tangible rewards when something is already intrinsically motivating, since this has the potential to be counterproductive and decrease interest (the overjustification effect).
We want to build upon strengths, values, and intrinsic motivation. We need to identify primary interests and use this as our basis for teaching and career building. Thomas Armstrong talks about “niche construction,” where an individual is matched to a supportive environment that will enable them to realize their potential. It aligns strongly with Carl Rogers’ and Abraham Maslow’s notions of self-actualization, the realization of our full potential and authentic selves. Neurodiversity advocate Judy Singer tells us that it is important to enable people to use their abilities and talents to support themselves. Tools such as the CliftonStrengths and Values in Action can help identify strengths to build insight and live out a value-based life. The Strong Interest Inventory can further elucidate our interests and direct us toward careers that match up with our interest profile. For children, it is best to take an individualized, child-led, play-based, and naturalistic approach to teaching and therapy. This approach allows us to clarify and build upon values, interests, and strengths.
Token economy systems introduce market norms into the relationship
Under the umbrella of external reinforcement for behavior change are behavior charts (i.e. point sheets and clip-up charts) and token economies (i.e. sticker charts). Behavior charts and token economies often begin with a negotiation over the conditions to be met in order to receive the rewards. These contingency programs encourage individuals to earn symbolic tokens, which may be traded in for a highly valued reinforcer. Unfortunately, the negotiations have a power imbalance, where one is holding the reward as a contingency for desired behavior without addressing inherent needs of the individual. Proponents often speak to the effectiveness of these programs for behavior management and for teaching individuals to work toward a preferred reward, similar to what adults do every day as they work toward a paycheck. However, the use of external rewards reduces intrinsic motivation, creates anticipatory anxiety, and encourages a tit-for-tat reward economy. The result is often that individuals will only engage in desired behavior when there is compensation (“what’s in it for me”). Parents who use this strategy are introducing market norms (system of payments, debts, contracts, and customers) into their family life, a setting where social values and norms should be emphasized. Additionally, innate tendencies to engage in prosocial behaviors are reduced when rewarded with external reinforcers.
Token economies are incompatible with a trauma-informed classroom. They assume that individuals have full control over their emotions and behavior, which is often not the case for children. Children notoriously have a developing prefrontal cortex and need additional support with executive functioning. It is excruciatingly difficult for children to self-regulate and much easier to co-regulate, but these reward systems place the burden of emotional regulation solely on the child. The use of behavior programs encourages emotional suppression and masking in order to earn rewards and avoid getting a “red day,” which is exhausting (autistic burnout) and may have negative impacts on mental health. Use of publicly displayed behavior charts and token economies creates an environment of shame for the inability to earn those rewards, which I imagine is antithetical to the aim of most behavior management programs. Our aim should be to teach children about their emotions, including identification/labeling, precursors, autonomic shifts, function and purpose, body response, thought responses, distress tolerance, sensory self-soothing, and so on. Emotions are complex, so we are doing a disservice if we add layers of evaluation with rewards and punishments.
Many schools use token economies and behavior contracts as contingencies for earning recess time (Premack Principle). However, withholding recess time from children is counterproductive, since it has been shown that additional recess improves desired classroom behaviors. Additionally, it is well-established that recess has significant benefits for physical, psychological, and social well-being and is recommended by the American Academy of Pediatrics. Unstructured free play at recess increases prosocial behavior and academic achievement. It is respite that helps prevent burnout. Since it is foundational to child development, it should never be used as part of a contingency program. Ironically, teachers who attempt to manage student behavior through punishments that remove recess are likely to exacerbate problematic and disruptive behavior.
Support attachment needs by building connection
Other strategies for modifying behavior include punishments, such as time-outs. Although many practitioners have already discontinued these practices and have shifted to “time-ins,” it is worth mentioning the harm caused by punitive, coerced isolation. Time-outs sometimes encourage individuals to just take a break to reflect on their behavior, cool off, and then given an opportunity to demonstrate “appropriate” behavior, which is then reinforced. However, social isolation and rejection is often experienced as shame, leading children to overidentify with the label “bad,” struggling to understand that it is their behavior being reprimanded rather than the whole self. We need to be particularly mindful of the potential for harm caused when time-outs are delivered with anger, emphasize social exclusion, and disregard attachment science.
Attachment science tells us the importance of forming safe and secure relationships with caregivers for psychological well-being and future quality of life. Disruption of these relationships can have harmful and potentially traumatic effects. Establishing oneself as a reinforcer (eg. pairing) and setting up contingencies with preferred caregivers tells children that relationships, affection, and safety must be earned. It is psychologically manipulative, exploitative, and eerily similar to love-bombing. The relationship becomes transactional and a poor model of a securely attached relationship. Contingencies placed on the relationship likely leads to masking, fawning, and pleasing behavior, which could make individuals more susceptible to abusive relationships.
Planned ignoring of undesirable behavior, an extinction strategy implemented to reduce target behaviors by withholding attention as a reinforcer, has the potential to cause attachment wounds. Planned ignoring seems to ignore its uncanny similarity to learned helplessness. Learned helplessness is a theory of depression that suggests individuals will stop trying to change a negative circumstance after repeated unsuccessful attempts, learning that the situation is hopeless and they have no control over outcomes. Similarly, planned ignoring teaches that regardless of how much an individual engages in a “problem” behavior, there will be no attentional reinforcement provided, so the individual stops trying (behavior extinguished), which can be particularly harmful with self-injurious behavior. Extinction strategies assume that behavior is intentional and seems to ignore that many “problem” behaviors stem from an autonomic shift. Clinicians are now shifting toward co-regulation strategies rooted in polyvagal theory to help manage maladaptive behavior, so rather than planned ignoring of attention-seeking behavior, we work to connect with dysregulated individuals to build an environment of safety and trust.
An environment of safety and trust encourages emotional expression by approaching “challenging” behavior with curiosity, nonjudgment, and compassion. Many therapeutic interventions are quick to label behavior as “problematic” or “challenging,” with treatment goals written to reduce or eliminate, rather than allowing for emotional expression and providing support. Goals often seek to reduce or eliminate innate autistic behavior. Throughout my career, I have seen reinforcement strategies implemented to reduce stimming (a self-regulation strategy), increase eye contact (can be physically painful for autistic people), limit conversations on preferred topics (teaches children their interests are unimportant and/or shameful and that reciprocal communication is subject to rewards), and limit autistic play (rather than teaching open-ended, diversity of play). Neurodivergent people lose their humanity when we use conditioning strategies to take away their way of being.
Although I have extensive experience and knowledge on this topic, there is a lot more for me to learn. If you have any additional insights, such as first-person experiences and/or publications, please reach out. I’m always excited to build upon my understanding and open to taking in new information.
