AUTHORS: Rachel A. Bowman, PhD,a and Jeffrey P. Baker, MD, PhD,b on
behalf of Duke University School of Medicine
a
Department of Psychiatry, Duke University Medical Center, Durham, North
Carolina; bTrent Center for Bioethics, Humanities, and History of Medicine,
Duke University School of Medicine, Durham, North Carolina
Address correspondence to Rachel A. Bowman, PhD, Durham Child Development
and Behavioral Health Clinic, Duke University School of Medicine, 402 Trent Drive
#2906, Durham, NC 27705. E-mail: rachel.bowman@duke.edu
Accepted for publication Nov 1, 2013
Drs Bowman and Baker approved the final manuscript as submitted.
KEY WORDS
autism, applied behavioral analysis
ABBREVIATIONS
ABA—applied behavior analysis
UCLA—University of California at Los Angeles
doi:10.1542/peds.2013-2583
Screams, Slaps, and Love: The Strange Birth of
Applied Behavior Analysis
On May 7, 1965, an extraordinary photo
essay titled “Screams, Slaps, and Love”
appeared in the pages of Life magazine. It portrayed the lives of 4 “utterly
withdrawn children whose minds are
sealed against all human contact and
whose uncontrolled madness had
turned their homes into hells.”1 Their
diagnosis was “childhood schizophrenia,” the term applied at the time to
the condition we know as autism. Two
were nonverbal, 2 others had no language other than endlessly repeating
television commercial jingles, and all
4 exhibited very disruptive behaviors
such as head-banging to the point of
bruising.
The article’s focus was on a novel
treatment that had recently been developed for autism at the University of
California at Los Angeles (UCLA). In an
age when psychoanalytic ideas dominated therapy for autism in the United
States, this new intervention was grounded
in behaviorism.2 The therapists in the
photo essay were depicted using rewards and punishments to change the
children’s behavior. Mimicking speech
led to food and hugs; uncooperative
364
behavior was met with scolding and
stern shaking. The essay’s most disturbing image showed a therapist administering an electric shock to one
recalcitrant child (Fig 1).1
It is hard not to look at “Screams, Slaps,
and Love” without a feeling of repugnance, if not horror, a depiction of the
“dark age” of the treatment of autism.
FIGURE 1
Therapist administering an electric shock to
one recalcitrant child.
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Yet for many of the article’s original
readers, its message was one of hope.
The climax of the essay was a dramatic
image depicting a mother’s joy after
her son hugged another child for the
first time. In hindsight, the article
marked one of the earliest appearances of applied behavior analysis (ABA)
in popular culture, one of the cornerstone therapies used for children with
autism today. Far from alienating parents, it provided hope for children with
extreme behavior problems and played
a critical role in galvanizing the rise
of the Autism Society of America. Yet
it pointed forward to the controversies
that would continue to beset ABA
for the remainder of the century as
well.
When the UCLA studies were conducted,
parents of children with autism had
little support and even fewer options.
Psychiatrist Leo Kanner had described
the syndrome for the first time only 2
decades earlier.3 By the 1950s, child
psychiatrists had developed an elaborate psychodynamic explanation for
the condition, regarding it as an analog to the emotional withdrawal seen
MONTHLY FEATURE
in abused and institutionalized children.4
Bruno Bettelheim, an unconventionally
trained psychoanalyst in Chicago,
brought these ideas to a wide audience in his best-selling 1967 book The
Empty Fortress.5,6 It described his program at Chicago’s Orthogenic School
that removed autistic children from
their allegedly abusive families and
provided an environment allowing complete expression of their “repressed”
egos, to the point of spitting, defecating, and biting caregivers. Reviewers
were moved by the dedication of Bettelheim and his staff, seemingly unaware of the message that was
being foisted on so-called “refrigerator
mothers.”7 In the end, Bettelheim’s data
were shown to be deeply flawed, but
not before they added even greater
misery to the lives of mothers of children with autism.
The philosophy exemplified by ABA
could hardly have been more different.
Its roots were in behaviorism rather
than psychoanalytic theory. Behaviorism began in the early 20th century
and flourished with the work of B.F.
Skinner and colleagues in the mid-20th
century. From the ABA perspective,
treating autism did not require understanding its etiology or parental
dynamics. Instead, changing behavior
was a matter of reward and punishment. ABA’s champion was outspoken
UCLA psychologist Ivar Lovaas, whose
matchless confidence was exemplified
by his oft-quoted claim that had he
treated Adolf Hitler as a young child
he could have turned him into a nice
person.8 Lovaas believed that he could
effectively treat severe childhood problems such as aggression and self-injury
without taking into account underlying etiology, through intensive positive
and negative reinforcement of overt,
external behavior. Although his UCLA
studies were performed in an institutionalized population, he sought to educate
parents to become agents of therapy.9,10
Perhaps predictably, ABA’s most vocal
critic was Bettelheim, who charged
that Lovaas’s work reduced children
to the “level of Pavlovian dogs”5(p410)
and “pliable robots.”5(p412) Such arguments at first appealed to many in the
educated public, who saw Bettelheim
as exemplifying humanistic and progressive values. It was the parents of
children with autism who were most
victimized by his writing and who
would eventually challenge his public
authority.
As detailed by sociologist Gil Eyal and
his colleagues, “Screams, Slaps, and
Love” played an interesting role in this
story.11 Not far away, Bernard Rimland, a Navy psychologist based in San
Diego, ignited what would eventually
become a widespread revolt against
the psychogenic theory of autism. After recognizing that his own son had
autism, Rimland researched and in
1964 published his own book challenging the “refrigerator mother” theory, Infantile Autism.12 Parents wrote
to Rimland requesting help for their
children, but he quickly realized he had
little to offer. After publication of the
1965 Life magazine article, parents inundated both Rimland and Lovaas with
letters pleading for more services and
effective interventions for their children with autism. As a result, Rimland
met Lovaas and observed his work at
UCLA. After trying the therapy on Rimland’s son and seeing progress, Rimland and Lovaas formed an alliance
with a dynamic group of parent advocates. Out of this network emerged the
National Society for Autistic Children,
today’s Autism Society of America.13,14
To be sure, the use of aversive techniques such as electric shock deeply
divided the autism community for many
years. Lawsuits charged that the use of
shock was tantamount to psychological
abuse that could leave lasting emotional trauma.15 Vocal critic C.D. Webster portrayed shock therapy as an
PEDIATRICS Volume 133, Number 3, March 2014
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abuse of power by mental health professionals in institutional settings that
should no longer be tolerated.16 Interestingly, few questioned the efficacy
of aversive therapy, and many parents
came to its defense as the only intervention that made their families’ lives
tolerable. Eventually the rise of effective
positive alternatives gave ABA advocates
confidence that positive reinforcement
alone could still be effective.17,18
The 1965 Life magazine article significantly altered the landscape of autism
treatment and research. Although almost a half-century has passed since
its publication, controversy and hope
persist. Despite validation in numerous
studies and the endorsement of the
US surgeon general,19 ABA continues to
be attacked as an overly mechanistic
strategy that fails to generalize to realworld changes in behavior. Such critiques often fail to take into account
that ABA, like autism itself, has come to
incorporate a spectrum of approaches
grounded in shaping behavior in more
naturalistic ways, never including physical punishment. In other words, today’s
ABA is not the ABA of 1965 and does
not include aversive techniques. Nonetheless, “Screams, Slaps, and Love”
foretold of the birth of a cutting-edge
and effective treatment for autism, and
the roles of professionals and parents
were newly defined and intertwined.
Perhaps its greatest legacy was the
establishment of parent and patient
advocacy groups that have continued
to shape autism today.
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FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Dr Baker’s research is supported by the Josiah Charles Trent Foundation.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to report.
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BOWMAN et al
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Screams, Slaps, and Love: The Strange Birth of Applied Behavior Analysis
Rachel A. Bowman and Jeffrey P. Baker
Pediatrics 2014;133;364; originally published online February 17, 2014;
DOI: 10.1542/peds.2013-2583
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright © 2014 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
Downloaded from by guest on March 6, 2016
Screams, Slaps, and Love: The Strange Birth of Applied Behavior Analysis
Rachel A. Bowman and Jeffrey P. Baker
Pediatrics 2014;133;364; originally published online February 17, 2014;
DOI: 10.1542/peds.2013-2583
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
/content/133/3/364.full.html
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2014 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
Downloaded from by guest on March 6, 2016