Questions to Consider When Choosing a Therapy Modality for Your Child
We have more information now than ever before about the brain, human development and relationships, and the myriad ways these are connected to each other. Neuroscience research and interpersonal neurobiology can help explain confusing or aggravating behaviors we see in those around us, and even in ourselves. For parents of children with brain-based differences, this information is incredibly powerful. It has the ability to transform our relationships with our children, shifting permanently the way we view their behaviors, and empowering us with knowledge that we can use to advocate for our children in ways that lead to better outcomes.
For this reason, I’m always learning as much as I can about the latest neuroscience research (as it relates to children with brain-based differences and challenging behavioral symptoms) and striving to make it digestible and actionable for the parents with whom I work.
One of the key questions parents and I frequently return to is this: How does neuroscience research and the neurobehavioral approach to parenting align with what you’re experiencing from the therapies in which your child participates.
A Brain-Based Approach to Supporting Your Child
The neurobehavioral approach, which is rooted in neuroscience research, encourages us to view behaviors as symptoms of our child’s brain differences. This means we need to move away from a goal of behavior management, and instead look beneath the behavior for the true, foundational cause. When we do this, applying this framework to our unique child and developing accommodations specific to their environment and lagging cognitive skills, we see challenging behavioral symptoms decrease over time. You can learn more about this approach through dozens of blog posts on my website, and also by reading both Dr. Mona DeLahooke’s book, Beyond Behaviors and Dr. Ross Greene’s book, The Explosive Child, each of which approach behaviors through a lens that considers brain development and function to explain challenging behaviors.
Challenging behavior is our child saying to us, "This isn’t working for me. I’m experiencing pain and distress. I need help."
When challenging behaviors escalate or increase in intensity, this does not mean we change course and move to a more traditional behavior modification approach. No matter the intensity level of a child’s behaviors, the interventions must look at brain function and nervous systems as the primary focus for intervention. Challenging behavior is our child saying to us, “This isn’t working for me. I’m experiencing pain and distress. I need help,” which should cause us to move towards them with compassion and empathy, rather than an emphasis on greater control and punishment.
If we consider intensely challenging behavioral symptoms through a brain-based lens (informed by neuroscience research), we see how the behaviors could be a result of several factors. One possibility might be a chronic “poorness of fit” between the child’s unrecognized brain-differences and lagging skills in specific environments. Or, it could mean that the child’s fragile nervous system needs more co-regulation in order to settle. For this reason, when a child’s behavioral symptoms are more intense, it requires the adults in their lives to move toward a focus on regulation, safety, relationship and accommodations, and to ensure we are not falling back into a behavioral lens for managing and gaining “compliance” from the child.
The other critically important factor that a brain-based approach encompasses is identifying where a specific child’s “window of tolerance” for frustration lies. For most kids with brain-based disabilities, this window of tolerance is quite narrow, meaning the smallest frustrations cause big reactions. This isn’t a character flaw, it’s about brain-differences and lagging skills. Frustration tolerance is a cognitive skill that develops over time, one which allows human beings to be more flexible, agreeable, and to manage disappointment and frustration “appropriately.”
So, when we (for example) encourage our children to do “more” in the way of greater independence and expanding social skills, we need to recognize what we’re also requiring of them from a cognitive skills standpoint, and always be mindful of their window of tolerance. If we can challenge our children and help them grow with appropriate accommodations in place, all while keeping them regulated and inside their window of tolerance— excellent! We’ve found that balance. If we push them outside their window of tolerance, we see this manifest through dysregulation and challenging behaviors. Once our child is dysregulated, they are out of their thinking brain and no longer have the capacity to learn and grow until they’re once again regulated.
With this information as preface, let’s take a quick look at how this brain-based lens applies to some common treatment modalities parents are asked to consider for their children experiencing challenging behaviors.
Applied Behavioral Analysis (ABA)
There are many neurobehavioral differences that overlap with symptoms we would typically see in a child with autism. Pre-natal toxic stress (due to substance exposure of pre-natal trauma), post-natal trauma, neuroimmune conditions such as PANS/PANDAS, and ADHD are just a few that can appear quite similar to autism from a behavioral standpoint. For all of these diagnoses, the brain is the organizing principle, meaning that each of these diagnoses suggest that something in this child’s neurodevelopment is not “typical.” These diagnoses tell us that the individual has a brain that has been changed in function and structure, for one reason or another, and because of this brain-difference, they experience difficulty with seemingly simple cognitive skills that neurotypical individuals have the privilege of rarely, if ever, needing to consider. When individuals with these diagnoses are not provided with necessary accommodations to support them in their lagging cognitive skills, we see challenging behavioral symptoms result.
Again, the path to fewer challenging behaviors for kids with all of these diagnoses is what neuroscience tells us about the brain-behavior connection, and the role relationship plays in all of this. It is about recognizing the brain differences, creating accommodations for them, and supporting the child’s fragile nervous system with co-regulation. It does not involve behavioral compliance through the use of rewards, punishments, and cohesion.
So, what does this mean when considering ABA?
Applied behavioral analysis (ABA) is a type of therapy that seeks to improve social, communication, and learning skills through positive reinforcement. It is an intensive training program consisting of an elaborate system of rewards, with the goal of having children comply with external directives and to memorize and engage in specific behaviors. The treatment focuses on changing difficult behaviors through positive reinforcement, providing rewards for positive behaviors while generally ignoring unwanted or undesirable behavior.
Before we discuss what ABA therapy may be lacking, and why it fails to align with a brain-based approach to parenting, I do not want to shame or directly criticize the ABA therapists who care deeply for children and were trained and believe in this model. What I hope will emerge is the presentation of an alternative view for these therapists (and parents) to consider, a perspective that is rooted in current neuroscience research and relational sciences.
I always begin from the foundational understanding that neuroscience research supports and explains neurodiverse children, their unique brain function and nervous system, and how exhibited behaviors are symptoms of how stable (or not) that nervous system might be. When we are working with (or parenting) children with brain-based differences, we have an obligation to look beneath the behavior to the ways in which that behavior is symptomatic of something deeper. This is the path to helping our children settle (meaning, to experience fewer challenging behaviors). As long as the primary focus remains on surface behaviors (which is what ABA promotes), we won’t see behavior improvements (and if we do, they are often temporary) because true improvements are not actually about the surface behaviors at all. Interventions that do not consider a child’s lagging cognitive skills as a result of their brain-based disability, or the fact that they have a more fragile nervous system that needs larger doses of co-regulation (from a regulated adult) to experience relational safety, will continue to fall short in helping alleviate the challenging behavioral symptoms.
When we ignore, or worse, punish children for their behavioral symptoms, we are communicating that we (as the adults) believe these behaviors are willful and intentional — instead of symptoms — and therefore communicate to the child that they are not worthy of our (the adult’s) care and attention. Our care and attention are then perceived as conditional. When a child’s distress (which is communicated through challenging behaviors) is consistently ignored over a long period of time, this can cause toxic stress, shame and anxiety. If we instead view these challenging behaviors as symptoms of our child’s brain-based differences, and a result of their lagging cognitive skills, it moves us from a place of wanting to simply extinguish the behavior at all costs to wanting to provide our child with support and accommodations; something they are entitled to, the same as any other child with a physical disability.
Cognitive Behavioral Therapy (CBT)
Cognitive behavioral therapy (CBT) is a common form of “talk therapy” that is most often suggested for young adults and adults. In CBT, a client works with a therapist to become aware of inaccurate or negative thinking, so they can then view challenging situations more clearly and respond to them in a more effective way. It often involves “homework,” where the client builds upon what they learned in session with their therapist and applies it to their daily life. The therapy itself involves steps such as identifying troubling situations, becoming aware of thoughts and emotions as they relate to these problems, identifying negative or inaccurate thinking patterns, and then finally reshaping those patterns.
CBT is an evidence-based therapy that certainly works for many individuals who participate, but what if the individual is neurodiverse? What should be considered? First, we need to consider the cognitive skills involved in fully participating in and benefiting from this therapy, and whether or not the individual being referred to CBT has those skills firmly in place.
If we look at just a few of the cognitive skills involved in CBT, the list of complex brain tasks soon grows lengthy: verbal processing; being able to reflect on past experiences and tie them to the present moment; generalizing (taking what they learn in session and applying it outside of session); executive functioning skills (such as completing homework in between sessions); emotionally regulating through difficult experiences or thoughts; identifying problems and, from there, the steps to move through those problems. If an individual is still building these specific skills, they will soon become overwhelmed by the task of participating in this therapy. And this will, more often than not, become most evident through challenging behaviors (refusal to participate or even attend, shutting down and refusal to talk, etc.).
Social Skills Groups
Social skills groups for children are an excellent way to help many kids learn strategies for conversation, friendship, and problem-solving. They are typically small groups led by an adult, with the goal to teach children in the group how to interact appropriately with peers their age.
So, why might they be a poor fit for a child who struggles with brain-based differences?
Again, we return to what neuroscience teaches us about brains that work differently. One of the foundational pieces of information adults must have about kids with brain-based differences is the ways in which they experience dysmaturity. Dysmaturity is the gap between an individual’s chronological and developmental (social/emotional) age, as dictated by societal norms. A child experiencing dysmaturity is not “acting like a baby,” they are lagging behind in skills that put them in a different place (socially and emotionally) than where society would expect them to be for their chronological age. “Acting appropriately” for a child with brain-based differences may look like a physically mature 12-year-old who presents more like a 6-year-old in the way they interact with peers, navigate the complexities of friendships, and engage with those around them. If this child is placed in a social skills group with kids of a similar chronological age, and there is no consideration or factoring in of the dysmaturity they experience, the group will likely be a poor fit for the neurodiverse child, leading — again — to challenging behavioral symptoms.
Ask and advocate
The question naturally arises, what happens if a professional is encouraging you to have your child participate in these or any other type of therapy? How do you know if your child’s very unique brain function is being considered at all? I encourage you to ask the provider about their beliefs regarding the brain — behavior connection, lagging cognitive skills, relational safety and nervous system health — to then draw your own conclusions about whether or not that particular provider’s beliefs and treatment approach align with the neurobehavioral model of seeing a child as having a brain-based disability that requires accommodations (versus consequences, intentional ignoring or punishment).
I also highly encourage parents to be curious about any treatments deeply rooted in the behavioral lens, ones which view behavior as something to manage through sticker charts, consequences, ignoring or exerting power and again, and to reflect on how that treatment aligns with all we know from relational neuroscience research.
Interested in learning more about how your child’s unique brain works differently and what this means in terms of helping them experience fewer challenging behaviors? You can visit eileendevine.com to learn about the Brain First Parenting program and The Resilience Room membership community.
Eileen Devine works in Portland, OR as a therapist and coach supporting parents of children with special needs. She is also a consultant for families impacted by FASD, PANS/PANDAS and other neurobehavioral conditions through her private practice, working with families nationally and internationally. She lives with her husband and two amazing kids, one of whom happens to live with FASD. For more information, visit eileendevine.com.