Stop Recommending Behavioural Therapies

Jillian Enright

The definition of “success” in these programs is compliance

To my fellow mental health professionals

I will consider it a job well done if our collective professions resolve to never recommend any type of behaviour therapy ever again.

Hear me out (parents, especially parents of neurodivergent and disabled children, you will definitely want to hear this too).

I’ve recently railed against Applied Behavioural Analysis (ABA) and other behavioural therapies for autistic children — evidence-based and research-driven arguments, but objections nonetheless.

Apparently the idea that this is a Good and Useful approach has seeped into the ADHD community despite autistic adults, researchers, and many experts screaming into the void to STOP harming children with these so-called “treatments”.

Recently a Psychiatrist in the Division of Developmental-Behavioural Pediatrics (so no bias there, of course), along with fellow Stanford colleagues, published a research letter stating not enough parents were referred to Parent Training Behaviour Management (PTBM).

First of all, their data was gathered from a grand total of 32 patients. Thirty two. That is a sample size so small the results are in no way generalizable. Secondly, the measure of success used for behavioural interventions is compliance.

Do we really want compliance and obedience to be our primary goals when it comes to supporting our children?

I’m going with a hard no on this one, and I’ll tell you why.

What is PTMB?

PTBM, in essence, teaches parents how to administer ABA-like programming in their own household. So now, not only do clinicians want children to attend behaviour therapies to be trained like puppies, they want their households to be a training centre as well.

Great. Now these children will have no escape from this dehumanizing, demeaning, coercive training.

For those unfamiliar, PTBM focuses on “increasing parental praise, positive attention, and reinforcement for appropriate child behaviour.” Ew. Again, they’re human beings, not puppies.

PTBM encourages “using disciplinary strategies such as timeout, consequences, and ignoring —ignoring the behaviour, not the child”, they say!

They’re the same thing. Behaviours are external manifestations of the child’s inner experiences. To ignore the behaviour is to ignore the child’s feelings.

Timeouts

Timeouts teach children they will be sent away or left alone when they are experiencing intense, sometimes overwhelming, feelings.

The premise is that if we provide a consequence for “inappropriate behaviour”, such as a child yelling and saying unkind things for example, they will learn not to yell and say unkind things because it results in being punished with a time-out.

“If they don’t make good choices, we punish them until they remember to be kind… I am going to be unkind to you in the hopes that you snap out of it, and in the future, do the exact opposite of what I am doing to you right now.” 
— Dr. Jody Carrington

In order for timeouts to be effective, three things must be true:
  1. The child must be having a tantrum on purpose — Their yelling must be a thoughtful, conscious, and intentional behaviour acted out in an attempt to get what they need or want.
  2. We must also assume the child already has the skills and knowledge to ask for what they want or need in a more socially acceptable way, but chose not to, and instead chose yelling.
  3. The child must also already have the skills and neurodevelopmental capability to self-regulate, so they can calm themselves down while in time-out, reflect upon their “inappropriate” behaviour, regret their actions, and resolve to behave differently in the future.

I can guarantee you that none of those are true approximately 99.9% of the time.

“Too often, caregivers, teachers, providers, and parents assume that a child is acting deliberately, when in fact a behaviour is actually a stress response.” 
— Dr. Mona Delahooke

Planned ignoring

Similarly, planned ignoring teaches children that we emotionally disconnect and shut them out when they are having big feelings.

To ignore the behaviour is to ignore the child’s feelings.

When we ignore a child, we are communicating that we reject them when they experience strong emotions, and we are not available to help them work through those experiences.

I’m not suggesting we condone aggressive or unkind behaviour, in fact, I recommend the opposite.

Instead of meeting unkind behaviour with our own unkind response (such as ignoring, punishing, or banishing), we role-model empathy and kindness by responding to and soothing the child’s intense emotions, rather than focusing on their surface behaviours.

“When the parent accepts the inner life of the child, and the child is accepted, even if their behaviour is not, this strengthens the child’s secure attachment.” 
— Huges & Gurney-Smith

Co-Regulation

Co-regulation is what happens when children lose their cool and we maintain our composure. We create a safe and caring environment for the child to work through their feelings.

We let them know — through our words and actions — that their feelings are okay, and that they’re going to be okay. We will guide them through this challenging experience and help them make sense of it.

“Co-regulating means supporting children as they regain emotional composure, as well as teaching them skills that will help them stay balanced and regulated more easily in the future.” — Siegel & Bryson

We role-model empathy, comforting and soothing the child, so over time they learn how to do this for themselves.

Children’s concerning behaviours nearly always come from one (or more) of three things:

  1. Feeling unsafe or scared.
  2. Lacking the skills needed to deal with the present situation.
  3. Emotional dysregulation, and lacking the skills or developmental capability to self-regulate in order to problem-solve.
“Emotional co-regulation comes first, and this is how emotional self-regulation is developed.” — Dr. Mona Delahooke

Time-outs and planned ignoring address none of the above, and will instead exacerbate these issues.

Affect matching

Affect matching is when we match a child’s expression of emotion without actually experiencing the emotion. Both of those elements are extremely important.

“Knowing that you ‘get it’, while still accepting your child often calms your child and helps them to stay regulated.” — Hughes & Gurney-Smith

When we match a child’s affect, we are demonstrating empathy and understanding by matching their expression of emotion, while offering co-regulation by not getting swept up in their emotions (or our own).

For example:

Child comes home from school angry. “My teacher is such a jerk! I got in trouble for reading in class —for reading!”

Invalidating response

“Young man, we do not speak about teachers that way! What were you supposed to be doing instead?”

Never mind, you don’t understand!”

[Kiddo stomps upstairs to his room and slams the door].

Validating response

My teacher is such a jerk! I got in trouble for reading in class — for reading!”

That does seem unfair!” (Said with similar intensity, but without anger — be careful not to come across as mocking, you’re genuinely expressing that you see and understand what they are feeling). “Do you want to talk about it?”

It’s just stupid. I got distracted reading when I was supposed to be doing my work.”

Oh man, it can be hard when we get distracted, it happens to me all the time!

Yeah. I guess I should have been doing my work, but I forgot. I didn’t do it on purpose.”

Did you get caught up on the work once the teacher reminded you?”

Yeah, it was easy.”

Good job. Did you want to try to problem-solve, or do you think you can work it out with your teacher yourself?”

I’m good, I just think it’s unfair…. Can I call my friend now and see if he can play?”

Sure, bud.”

I used a simple example for the sake of brevity, but I hope this illustrates the point: when we focus on the surface behaviour, we miss the more important things going on beneath the surface. We also miss the opportunity to co-regulate and empathize, and we may also miss out on a teachable moment.

Final thoughts

When a child is first diagnosed with a neurodevelopmental disorder, such as autism or ADHD, many parents are wading into completely unknown territory. They’re worried and want to do what’s best for their children.

When they don’t know what that is, parents often turn to the experts, the ones in the white coats or holding the clipboard. Except neurotypical psychiatrists and paediatricians are not the experts on this.

I do not say this to undermine their education and medical expertise. I have great respect for these specialists, and have worked alongside many wonderful medical professionals.

That said, unless they’ve gone out of their way to specifically learn about neurodivergence and practice from a neurodiversity paradigm, or have personal experience with ADHD and autism themselves, then they are not the experts.

Neurodivergent people are the experts. Neurodivergent professionals are even better positioned to offer support and guidance from an educated and compassionate perspective.

When a parent feels overwhelmed with this new information and turns to their child’s doctor for advice, they should be given neurodiversity-affirming care and resources, and shown how to foster their child’s unique gifts and strengths.

Parents should not be told to make their child as close to neurotypical as possible, and they should not be told that ABA or PTBM are the “gold standard” of treatment.

They’re not, and they never will be.

© Jillian Enright, ADHD 2e MB

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References

Bannett, Y., Gardner, R. M., Posada, J., Huffman, L.C., Feldman, H.M. (2021). Rate of Pediatrician Recommendations for Behavioral Treatment for Preschoolers With Attention-Deficit/Hyperactivity Disorder Diagnosis or Related Symptoms. JAMA Pediatrics. https://doi.org/10.1001/jamapediatrics.2021.4093

Carrington, J. (2020). Kids These Days: A game plan for (re)connecting with those we teach, lead, and love. IMpress Books.

Delahooke, M. (2019). Beyond Behaviors: using brain science and compassion to understand and solve children’s behavioral challenges. PESI Publishing.

Hoffman, K., Cooper, G., Powell, B., Benton, C. M. (2017). Raising a secure child. Guilford Publications.

Huges, D., & Gurney-Smith, B. (2020). The Little Book of Attachment: Theory to practice in child mental health with dyadic developmental psychotherapy. W.W. North & Company.

Silkenbeumer, J., Schiller, E., Holodynski, M., Kärtner, J. (2016). The Role of Co-Regulation for the development of social-emotional competence. Journal of self-regulation and regulation, 2. https://doi.org/10.11588/josar.2016.2.34351

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Neurodivergent. 20+ years social work and psychology experience. I write about mental health, neurodiversity, advocacy, education, and parenting. Founder of Neurodiversity MB. CYW, BA Psychology.

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