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A Child Abuse Pediatrician's Look at Therapeutic Methods, Part 1

Updated: Feb 23, 2022

If you haven’t heard (and I can’t imagine what rock you’re living under if you haven’t), children’s therapy is at a crossroads. While most of the focus is on ABA, speech, occupational, and physical therapy are also coming under fire for techniques that have been labeled “abusive.”

Below, I’ve reviewed several therapy methods that are particularly concerning to the autistic community and others, and I’ll give you my perspective on them.


Reward Systems

Rewards are commonly recommended for parents when trying to modify a child’s behavior and are used by many therapists to entice children to participate in tasks they otherwise might not enjoy. This is done despite robust evidence that rewards don’t work and can harm children over the long term.

Rewards can produce behavior change in the short term, but the learned behaviors are rarely used once the rewards go away. What does remain is a need and expectation of external validation. By using reward systems, we teach children that their work isn’t valuable or meaningful if it doesn’t give an immediate reward. For children who already struggle with completing unrewarding tasks, this magnifies their problem.

It’s also important to remember that child abusers often reward compliance and secret-keeping with gifts. Using these methods normalizes the idea that doing uncomfortable things and getting rewarded for them is acceptable.

Preference Assessments

Preference assessments go hand-in-hand with reward systems. These assessments are done to identify a child’s preferred objects and foods, which then can be used as rewards. Aside from the problems with reward systems mentioned above, preference assessments have their own issues.

To put it another way, a therapist is conducting systematic testing to identify the rewards most likely to entice a child into compliance. This is incredibly manipulative in its own right, and is far too similar to the systematic grooming conducted by child sexual abusers for my liking.

Using Personal Items as Reinforcers

This is a particularly problematic version of a reward system. When personal items, like tablets, phones, or toys, are used as a reward for completing a task, an extremely problematic dynamic is established.

Here’s an example of how that might work. A child needs to complete an activity matching a picture to the first letter of the word. So, they might match D to a picture of a dinosaur. Before starting the activity, the child’s tablet is taken by the therapist. When the child completes 10 matches, they get to play on the tablet for 5 minutes.

That example might seem harmless. But what about this example. A husband wants to have sex with his wife. So he takes her phone. If she has sex with him, he’ll give her phone back to her.

The withholding of personal items pending the performance of non-preferred therapy tasks has the effect of normalizing withholding as part of healthy relationships. Normalizing abusive behavior, even with the best of intentions, is dangerous.

Planned Ignoring and Extinction

Crying is a completely healthy expression of emotion. And from an evolutionary perspective, it serves as an alert system, informing those around us that we need help. But crying isn’t the only way we communicate a need for help or attention. Sometimes children will go get a caregiver, or call out their name, or a million other ways of getting attention.

Despite knowing this, planned ignoring is a staple of education plans and children’s therapy. When a child does something to get attention in a way other than what the adults direct, the child is ignored. Of all of the examples of problematic therapy methods, this is the most confusing to me. I cannot reconcile the idea of loving a child and the practice of ignoring an expression of need.

The argument for planned ignoring is that children “need to learn how to ask for help.” That seems particularly insensitive to me. Children will learn quieter, less disruptive ways of asking for help when they have first learned that their needs will be met. Ignoring their requests for support has only one effect. It teaches children that their needs won’t be met by the adults who are supposed to protect them. So eventually, they stop asking and try to handle it themselves.

This is unacceptable. Planned ignoring systematically teaches children to ignore their own internal alert system. That alert system exists for one reason – to keep us alive. Ignoring the feeling of distress becomes a habit, and virtually assures that a child who is being abused won’t tell anyone. Because why would they, when they’ve been ignored all this time?

What Now?

I think it's far easier to poke holes in methods than to suggest new ones. But that doesn't really help anyone. So here are some things to think about:

  • Read more about the harm done by reward systems and some alternatives.

  • Consider poly-vagal theory and the idea of coregulation as an alternative to planned ignoring.

Part 2 coming soon!

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