A recently published article sought to determine the extent to which behaviorism and humanism can be reconciled (Shyman, 2016). However, the “current” conceptions of behaviorism and applied behavior analysis (ABA) used for the analysis were based on mischaracterizations, rendering moot many of the points made. Nevertheless, Shyman (2016) highlighted a very important question we believe all helping professionals should attend to: Should normalization be the focus of therapeutic goals? This response article was written to provide readers of this journal an accurate representation of behaviorism and ABA. We have also offered an alternative approach to answering the question of normalization that uses a behavior-by-behavior approach and individual client values as the deciding factors.
Great is the power of steady misrepresentation; but the history of science shows that fortunately this power does not long endure. (Darwin, 1962, p. 421)
A recent article in this journal began with an admirable aim (Shyman, 2016). The author hoped to continue a discussion regarding the philosophical positions of behaviorism and humanism to determine the extent to which the two are compatible. Responding to an article by Hayes (2012) and working from an assumption of incompatibility, Shyman concluded that behaviorism and humanism are irreconcilable. In addition, Shyman suggests significant changes to behaviorism need to occur “both philosophically and methodologically for such reconciliation to be achieved” (2016, p. 366). As behaviorists and practitioners of applied behavior analysis (ABA), we appreciate the critical issues raised by Shyman. We also welcome the opportunity for productive discourse about the characteristics of the disciplines we have been trained in and how effective collaboration can be achieved. In particular, we admire all attempts aimed at reconciling seemingly opposed theoretical approaches to understanding and helping other humans. However, some of the concerns raised seem to be based on a misunderstanding of behaviorism and ABA. To continue the discussion about the important issues raised by Shyman (2016), we hope to correct some of these misrepresentations.
As with many sciences, behavior analysis is often represented in public forums by people who are not behavior analysts (e.g., Autism Speaks, 2017; Rabin, 2015). This may lead to misrepresentation of both the science of behavior analysis and the underlying philosophy of behaviorism (e.g., Gobry, 2014; Hoge, 2016). Such misrepresentation may be harmful to individuals who could benefit from ABA but avoid it because of misconceptions they have heard, or because they are advised to avoid ABA by someone who is operating from misconceptions.
Misrepresentation of behaviorism and ABA may also be harmful to readers of this journal. Individuals with intellectual and developmental disabilities likely receive services from people spanning a variety of distinct professions (e.g., teachers, doctors, speech and language therapists, occupational therapists, behavior analysts; Brodhead, 2015; Cox, 2012). Many readers of this journal are therefore likely to contact behavior analysts in their daily work or know individuals who receive ABA services. At minimum, readers of this journal should have access to accurate and current information to help guide those interactions. For readers who regularly work with behavior analysts, successful collaboration toward common goals is unlikely without effective communication (Drotar & Sturm, 1996; MacDonald et al., 2010). Effective communication between disciplines will be more likely if all parties have an accurate understanding of the defining characteristics of all involved disciplines.
In his article, Shyman (2016, p. 368) hoped to establish several characterizations of behaviorism and ABA he finds incompatible with humanism. These (mis)characterizations are: (a) “the general framework of applied behavior analysis … [is] centered on the medical model of disability,” (b) “applied behavior analysis … situates autism spectrum disorder (as well as those with ASD) as a form of ‘enemy,'” and (c) “the social metaphor of ASD as ‘enemy' leads the greater field to address the efficacy of ‘therapeutic treatment' of ASD in terms of achieving (or approaching) normality.” We initially sought to understand exactly how the author came to view behaviorism and ABA in this manner, as these characterizations deviate significantly from the training and education we have received. Unfortunately, without sufficient citations or definitions, it is unclear exactly where Shyman obtained the information to support the (mis)characterizations of behaviorism and ABA he finds incompatible with humanism.
We have two goals in this reply article. First, we hope to point out errors in the previous article that led to claims and representations of behaviorism and ABA we deem false. Relatedly, we provide accurate and current conceptualizations of behaviorism and ABA. Second, we hope to highlight important considerations from Shyman's article that warrant further discussion. In turn, we hope an accurate understanding of behaviorism and ABA will aid collaboration amongst researchers and professionals spanning a variety of disciplines. Successful collaboration between behavior analysts and members of other professions will likely lead to improvements in care beyond the impact any single professional may have on their own.
Mischaracterizations of Behaviorism and Behavioral Methodologies
The first important distinction to be made is between radical behaviorism and methodological behaviorism. This is important for two reasons. First, differentiating between behaviorisms was central to the article to which Shyman responded (Hayes, 2012; p. 456). Second, depending on which behaviorism is being considered, the critiques put forth by Shyman (2016) range from somewhat accurate to completely inaccurate (Hayes, 2012; see Baum, 2005; Day, 1983; and Johnston, 2014; for treatment of different philosophies of behaviorism). The critiques would be somewhat accurate if one is considering methodological behaviorism. However, the critiques are inaccurate if one is considering radical behaviorism. The ability to differentiate between behaviorisms can be difficult for those trained outside the discipline as writers from various behaviorisms use similar technical jargon (Hayes, 2012). A full treatment of both methodological and radical behaviorism is well beyond the scope of this article. However, we will briefly outline radical behaviorism below and will write from that perspective throughout the article—mainly because it is the philosophical position underlying the content by which most ABA practitioners are trained (Cooper, Heron, & Heward, 2007, p. 13; Johnston, 2014).
Brief overview of radical behaviorism
Radical behaviorists generally agree on three points (Baum, 2005, p. 58). First, mentalistic explanations deriving from layman language are not helpful in a science of behavior. Here, mentalistic explanations are explanations that separate mental or nonobservable events from behavioral events and subsequently use the mental events to explain behavior. For example, saying “I ate the cookie because I'm impulsive” might be considered a mentalistic explanation if the speaker considers “impulsivity” to be the thing residing within the individual that caused the person to eat the cookie.
Mentalistic explanations are not practically useful and are logically false. Mentalistic explanations are logically false because they are category mistakes (Ryle, 1984) or use circular reasoning (Baum, 2005). Mentalistic explanations are category mistakes because they rely on the mentalism as a thing distinct from the observational instances used to define the mentalism. For example, if we were to list items belonging to the category of dairy foods—products containing or made from milk—we might say cheese, butter, and yogurt. However, if we included dairy foods in this list, that would be a category mistake of the kind we are discussing here. That is, dairy foods cannot be both an instance of the category dairy foods that is distinct from milk, cheese, and butter as well as the category label of dairy foods. Similarly, impulsivity cannot both be a thing separate from the impulsive behaviors used to define impulsivity and the category label of impulsivity. As Baum notes (2005), a likely objection would be that what defenders of mentalistic explanations mean by impulsivity is not the behaviors identified as impulsive. Rather, impulsivity is something underlying all of these behaviors that causes them. However, this argument quickly leads to circular reasoning. How do we know that someone is impulsive? Because they ate the cookie instead of vegetables. But, why did they eat the cookie? Because they are impulsive. But, how do we know that they are impulsive? And so on. The use of a mentalistic label as a causal explanation gives the illusion of the mentalism as an instance or thing that subsequently causes behavior. However, an attempt to pin down where impulsivity is, what it is made of, and how it influences behavior leads one in an explanatory circle.
The second generally agreed upon point by radical behaviorists is that mentalistic terms should either be avoided or redefined in a way that allows a researcher or practitioner to behave effectively relative to the subject matter. For example, rather than speaking of impulsivity as an entity, one could define impulsivity relative to the observed impulsive behavior (e.g., eating cookies for a snack instead of carrots). Such an approach is helpful because it offers a clear definition of when impulsivity is being observed (e.g., eating cookies for a snack), as well as how to reduce impulsivity (e.g., get people to eat carrots for a snack).
The final generally agreed upon point by radical behaviorists is that thoughts, feelings, and other private events are natural phenomena that are subject to the same laws and principles as all public behavior (Skinner, 1945). Here a private event is any behavior or event that is observable by only one person (ibid). The significant point made by Skinner is that the skin is not an important boundary for defining private or nonprivate events (ibid). Stated differently, private events are behavior and are not of a different substance than publicly observable behavior. Understanding how radical behaviorism conceptualizes private events will be important further in the article when we discuss how behaviorism includes internal motivation in an analysis of causes of behavior.
Radical behaviorism vs. Shyman's behaviorism
Shyman labels behaviorist methodologies as “mechanistic, absolutist, symptom-focused, and oriented principally around external motivation” (2016, p. 366). Unfortunately, definitions of what exactly mechanistic, absolutist, and symptom-focused mean were not provided. In addition, exactly how these adjectives are applicable to behavioral methodology was not outlined. Nevertheless, we will discuss how these labels are mischaracterizations of behavioral methodology based on our interpretation of these labels.
Behavior analysis takes a functional—not symptom-focused—approach to behavior (Skinner, 1938, p. 8). This means the holistic contingency that causes behavior is the focus of analysis. This holistic contingency is comprised of four components: (1) motivation, (2) the context in which the behavior occurs, (3) the behavior itself, and (4) the outcomes that reliably follow the behavior (e.g., Iwata, Dorsey, Slifer, Bauman, & Richman, 1982; Michael, 1993). It is true behavior analysts operationally define responses so they can be reliably measured. However, the focus of behavior analysis is not solely on the response (i.e., the symptom). A behavior analyst also seeks to understand behavior relative to motivation, contextual events, and the events that reliably follow the behavior (e.g., Iwata et al., 1982). Intervention is then individualized relative to each person based on the unique cause(s) of the behavior, the goals of the client and their caregivers, and the practical limitations within the intervention environment (see Behavior Analyst Certification Board [BACB], 2014). For example, behavior analysts may teach a child who engages in self-injurious behavior or aggression to instead ask for what they want (e.g., Carr & Durand, 1985; Durand & Moskowitz, 2015). In addition to adapting the intervention to each person and his or her relative goals, functional approaches adapt and modify the intervention over time based on changes in ability demonstrated by the client. In total, it is unclear how taking a functional approach based on a client-centered cause of a behavior could be anything other than “adaptable, person-centered, relativist, [and] holistic”—the characteristics Shyman assigned to humanistic approaches to contrast with behavioral methodologies (p. 366). (Note: We do acknowledge that poor applications of ABA may exist [e.g., routinized discrete-trial programs using a cookbook type approach to selecting learning goals]. However, it should be noted that such a nonindividualized approach is not reflective of the approach board-certified behavior analysts are trained to use and of the requirements of the Code of Ethics for Behavior Analysts [BACB, 2014].)
The radical behaviorist's perspective on motivation can be captured by the concept of motivating operations. Motivating operations refer to a context or set of internal and external stimuli that (a) momentarily increases or decreases the effectiveness of a stimulus as a reinforcer or punisher (see Catania 2013 for definitions of reinforcer and punisher); and (b) changes the probability of behaviors that have been previously associated with the reinforcers and punishers (Michael, 1982). For example, hunger is a state of deprivation (i.e., a context) that momentarily increases the effectiveness of food as a reinforcer and increases the likelihood of food-seeking behaviors. Motivating operations are inferred via objectively measured events (e.g., time since last consumption of food, water, etc.).
Behavioral methodologies also are not oriented primarily around external motivation while ignoring internal motivation (Shyman, 2016, p. 366). Behavior analysts recognize that public and private events (e.g., thoughts, feelings, emotions) play a role in motivation (e.g., Layng, 2017; Michael, 1993; Tapper, 2005). Private events are unique because they are only accessible to one person and may occur inside the organism (i.e., internally). However, both public and private events are susceptible to the same behavioral processes and are taken into account when determining what is motivating behavior (Skinner, 1953). Returning to the hunger example, the physical pangs felt when hungry are private events. That is, “hunger” likely involves physiological responses and events that are observable only by the person feeling the hunger pang. However, just because hunger pangs are not observable to a behavior analyst does not mean they would play no role in statements regarding why a person seeks out and eats food. They would just be one part of the set of contextual stimuli that comprise the motivating operation that leads to an increase in the effectiveness of food as a reinforcer and an increased likelihood of food-seeking behaviors. Stated succinctly, radical behaviorism does not ignore events internal to the organism in understanding what is motivating the organism. This is a common misconception about behaviorism that has been rebutted for decades (Skinner, 1974, pp. 4-5).
It is possible Shyman was not criticizing radical behaviorism or aware of the philosophical assumptions underlying radical behaviorism. Instead, the issue may have centered on external motivation relative to methods employed by behavior analysts in applied settings. However, criticizing the methods employed by behavior analysts in applied settings relative to external motivation fails in at least two ways.
Current technologies allow helping professionals to only change or manipulate things in the environment external to other individuals. This applies to teachers, speech and language pathologists, occupational therapists, and behavior analysts. We can only provide praise, positive affect, and other stimuli external to an individual to motivate them. If using events external to an individual to motivate them is what one finds distasteful, then this is a criticism of most, if not all, helping professionals—not just behavior analysts.
Demarcating internal from external motivation is extremely difficult. Some external sources of control are more salient and seemingly contrived than other sources. For example, trophies and star-systems may seem more salient or contrived in the influence on behavior compared to social praise in the form of receiving an “A” on a math worksheet. But the inability to identify an external motivating event does not equate to the absence of an external motivating event or the presence of an internal motivating event. In addition, a host of problems arise if one tries to determine whether a specific behavior was the result of internal, external, or a combination of internal and external motivation (Levy et al., 2017). Any claim that helping professionals focus solely on external or internal sources of motivation indicates a lack of understanding in current methods for measuring behavior and the complexity of many interacting variables that influence whether or not behavior occurs.
Because we provided an accurate description of radical behaviorism, we also will provide an accurate description of ABA. ABA is an applied science where the “behavior, stimuli, and/or organism under study are chosen because of their importance to [humans] and society, rather than their importance to theory” (Baer, Wolf, & Risley, 1968; 1987). ABA researchers and practitioners use the principles and processes shown to underlie human behavior to help a client change behavior toward their desired goal. That is, ABA is the elaboration of methodology inclusive of the principles of behavior and an experimental protocol allowing researchers and practitioners from a diverse range of disciplines to apply the methods. Clients could include individuals with intellectual or developmental disabilities, their parents/caregivers, smokers, sedentary individuals, business owners, or clients from any of the many societal domains that ABA practitioners work (Association for Behavior Analysis International, 2016).
Conflation of terms
A second set of mischaracterizations can arise if behaviorism (a philosophy) and ABA (a science) are conflated (e.g., Shyman, 2016), despite philosophy and science being distinct (e.g., Hartman, 1963; Kant, 1992; 1998). Distinguishing science and philosophy is important for two reasons. First, there is a significant difference between the range of phenomena that has been or can be examined through empirical methods (e.g., ABA) and the range of phenomena that a philosophical position can potentially account for (e.g., behaviorism). Second, the methods used to support a claim differ between science and philosophy (Hartman, 1963). Science relies primarily on systematic manipulation of the environment and direct observation. As a result, the science of ABA is methodology that researchers and practitioners from diverse disciplines could adopt if behavior is of concern. In contrast, philosophy relies primarily on logic and inference from available evidence. Granted, philosophical positions are constrained by empirical facts, and observations relate to empirical literature through logic and inference. However, science and philosophy are distinct methods of understanding.
Distinguishing the science of ABA from the philosophy of behaviorism is important relative to Shyman's claims (2016, p. 368). The science of ABA and the practical implementation of that science by behavior analytic practitioners can, and likely is, practiced without commitment to a philosophy of behavior (McDowell, 2012). The reverse is also true—one can be committed to a philosophy of behaviorism and never engage in ABA-related activities. As a result, the mischaracterizations about behaviorism and ABA may or may not be pertinent depending on whether one is talking about ABA or behaviorism (Shyman, 2016, p. 368). Taking one of the criticisms as an example, using scientific methods (ABA) to determine whether a behavioral intervention reduces rates of aggression does not provide evidence whether therapeutic treatment should focus on normality. Similarly, no amount of philosophical argument on the appropriateness of the medical model of disability will tell a practitioner whether a specific behavioral intervention will increase social interaction with peers. Lastly, the philosophy and assumptions of behaviorism do not commit a behaviorist to embracing or rejecting a normality approach to treatment or the medical model of disability.
Mischaracterizations may arise if ABA service delivery and the medical model are conflated (Shyman, 2016). For example, the medical model has been described as a normal/abnormal dichotomous framework used to identify appropriate levels of functioning in intellectual, social, and behavioral realms, and by which the main treatment goal is to attain or approximate normality (Shyman, 2016, p. 367). This framework conceptualizes disability as sourced within the individual, necessitating a cure of the disability or rehabilitation of the disabling conditions.
The medical model described above is distinct from the ABA service delivery model. In ABA service delivery, behaviors targeted for reduction or acquisition are not based on a normal/abnormal dichotomous framework, analysis does not focus on identifying appropriate levels of functioning, and the stated goals are not focused on attaining normality. ABA service delivery uses an understanding of human behavior derived from applied and basic behavior analytic research to help parents, caregivers, and/or the clients themselves change behavior toward the goals they have set for themselves or their loved ones (BACB, 2014). In fact, the Professional and Ethical Compliance Code for Behavior Analysts requires that the parent, caregiver, or client be the ones making that decision (BACB, 2014). The behavior analyst does not make that determination based on preconceived notions of what behavior should look like and how behavior relates to arbitrary definitions of normal/abnormal or appropriate/inappropriate. The parent, caregiver, and/or the client may choose to use whichever model of behavior they would like as their guide in making decisions—including the normality model if they so desire. But no model is inherently encompassed by ABA as a science or ABA as service delivery.
On eliminating autistic symptomatology and the neurodiversity approach
Conflation of ABA and the medical model of disability can result in another claim that needs to be addressed. Specifically, Shyman asserts ABA is considered effective based on its ability to “minimize, if not eliminate ‘autistic symptomatology,' therefore bringing the individual closer to normality” (2016, p. 367). It is true that some early researchers used language suggesting the effectiveness of ABA was determined based on how many individuals with autism were able “to achieve normal functioning” (e.g., Lovaas, 1987, p. 7). However, we would argue this is an outdated view that is not widely held by individuals within the behavior analytic community. Specifically, the assertion that ASD lies within the individual and needs to be removed is contrary to the functional and antimentalistic approach that characterizes behavior analysis.
The causes of behavior do not reside solely within the individual. The causes of behavior are influenced by many factors, including: the current environment, previous interaction with the environment, genetic predispositions influencing sensitivity to changing schedules of reinforcement and punishment, and genetic influences caused by natural selection that exist because the individual is a member of the human species. This necessarily requires an understanding of the behavior of those around the client and the dynamic interactions between everyone's behavior and the environment. In turn, the focus of intervention lies in changing the behavior of people that surround the client as much as it focuses on the behavior of the client. Relatedly, the behavior analyst does not hold “the ultimate power of provision” (Shyman, 2016, p. 369), and to believe so is to misunderstand how behavior functions. Behavior analysts may understand and use principles and processes of human behavior to help change the behavior of the client and those around them. But, the focus is on interactions between people and the environment, not on removing a disability from within an individual.
It is also important to note that diagnoses relying on normalized concepts of behavior are theoretically irrelevant to behavior analytic interventions. This leaves “autistic symptomatology” (Shyman, 2016, p. 367) as both an unrelated concept to ABA and an outdated approach to how behavior analysts help people with autism and related developmental disabilities. The important information for all behavior change programs are the current abilities of the individual and the abilities the individual or their caregiver would like them to have. Treating normalized diagnostic symptoms is not a defining feature of any behavior analytic program. Thus, we agree with Shyman that socially determined diagnostic criteria and symptomatology should not be an a priori focus of interventions and education for individuals with autism spectrum disorders. Instead, an individualized approach should be designed based on each person's unique abilities.
Of final discussion on the topic of normalization and normalized models is the alternative model of neurodiversity proposed by Shyman. Briefly, the neurodiversity model described by Shyman (2016) suggests society should focus primarily on the “acceptance and value of diversity” instead of rehabilitation or treatment for “neurodiverse” individuals. He acknowledges that some may view this position as an “over-romanticized notion of acceptance” (2016, p. 367), but describes it as a “positive step forward.” However, such an approach offers little guidance for ensuring the success of individuals with “neurodiverse” conditions in their current environments. Social acceptance of all individuals is a noble and worthy goal, but helping professionals are doing those individuals a disservice without teaching them the skills necessary to navigate their current world with sufficient independence. This holds true for all individuals, across all skill levels, in all educational contexts (e.g., individuals in K-12 special education classrooms, young adults seeking a college education, practitioners attending continuing education events; we thank an anonymous reviewer for highlighting the breadth in applying this notion beyond individuals in special education contexts).
Important Considerations Mentioned by
Shyman (2016) mentioned one topic we agree merits much greater dialogue and consideration from all professionals who work with individuals with autism and related developmental disabilities—including behavior analysts. That is, whether normalization should be the focus of therapeutic goals. Like the medical model, normalization can be difficult to define and disagreements are likely to occur. However, for this article, we will use the sociologically based definition of normalization offered by Foucault (1990). Foucault referred to normalization as the specification of conduct by which individuals are then rewarded for conforming, or punished for nonconforming, to the specified conduct.
Shyman poses a legitimate question asked by many within the differently abled movement: Is focus on individual conformation to, or deviation from, specified standards the best route toward improving the quality of life of people that are differently abled? Or, is a focus on changing society's accommodation of different abilities the best route toward improving the quality of life of people that are differently abled? Answering this question is far from being a binary decision. Rather, answering this question on a behavior-by-behavior basis seems more appropriate than an all-or-none decision in support or against using a normalization approach.
Teaching behavior relative to a normalized standard seems difficult to justify in some contexts. For example, individuals with autism and related developmental disabilities may have unique and idiosyncratic preferences and interests, or they may emit stereotypic patterns of behavior. It is hard to justify changing idiosyncratic preferences or reducing stereotypic patterns of behavior if they do not harm anyone, hinder the individual's ability to function in their environment or learn new skills, or prevent the individual from contacting greater amounts of preferred activities and reinforcers in their daily life. Stated differently, it seems difficult to justify intervening to change a behavior or preference if that behavior or preference does not harm or place undue burden on anyone (including the same individual's future self; e.g., Le Morvan, 2009; Morton, 2013). It is important to again note the BACB ethical code requires the client and/or their caregiver make the value claims relative to this decision—not the behavior analyst acting independently as some may perceive to be the status quo (Shyman, 2016, p. 369).
Teaching behavior relative to a normalized standard seems justified in some contexts. For example, many ABA programs for individuals with autism focus on teaching normalized communication skills. As a human being living within a larger society, everyone will need to communicate and interact with many people to meet their needs. Although immediate family members and a limited number of additional people (e.g., teachers, friends) may understand an idiosyncratic method of communication, the larger society likely will not. Requiring the larger society to accommodate and learn the unique communication style of every individual person in the society—autism or not—is not practical. Failing to teach an individual normal or typical communication behaviors relative to the society they live in can be severely limiting. This is especially true if the few people who understand the communication behaviors of one individual become temporarily or permanently unavailable. By failing to teach normalized communication behaviors, the probability of generalizing communication and social skills is low and the individual becomes limited in their ability to navigate their larger social world. It is hard to imagine ethically justifying anything other than a normalization approach relative to communication abilities.
Answering the normalization question on a behavior-by-behavior basis is more productive toward individualizing interventions. From a behavior analytic perspective, every behavior occurs within a unique context, is followed by a unique outcome, and is relative to unique motivating operations (i.e., the four-term contingency mentioned previously). The reasons why each unique behavior occurs is context dependent. It would be the direct opposite of personalized and individualized if we were to determine a priori that the whole of society surrounding a person should adjust to all behavior from one person or that the person should adjust all of their behavior to the larger society. It seems this decision should be made on an individual and behavior-by-behavior basis.
It is important for behavior analysts to foster and maintain communication with researchers and practitioners from other fields. It has long been argued by behavior analysts that a complete account of human behavior will likely require synthesis of research across several areas of science (Skinner, 1974). Successful interdisciplinary communication and collaboration will require others to be open to acquiring a basic understanding of the philosophy of behaviorism, the science of behavior analysis, and the extension of both to areas of social significance in ABA. Similarly, behavior analysts will need to be open to acquiring a basic understanding of the philosophy, science, and applied extension of other disciplines involved in synthesized research and interdisciplinary practice. Translating technical jargon to accomplish the above understanding is no easy feat. Nonetheless, constructive discussion and collaboration is the foundation for scientific progress toward solutions for social problems. Open and accurate dialogue is of necessity when the solutions are interdisciplinary in nature and miscommunication is likely to occur.
We commend all attempts toward interdisciplinary reconciliation and collaboration. It is hoped this article has corrected some of the mischaracterizations of behaviorism, behavior analysis, and ABA that were present in an earlier attempt at reconciling humanism and behaviorism (Shyman, 2016). In turn, we hope any future collaboration between scientific disciplines that comprise the readership of this journal will involve an accurate representation of behaviorism, behavior analysis, and ABA. Lastly, Shyman made several valid and important points to which all readers of this journal should attend. In particular, we second his call for greater dialogue on the long-term appropriateness of a normalization model for maximizing the quality of life for differently abled individuals. Rather than viewing it as a binary decision, we have offered an approach that involves making the decision on a behavior-by behavior basis and founded on the values of the individual client or his or her caregiver. We look forward to reading other approaches and opinions on this very important topic.
The authors thank Dr. Jesse Dallery for insightful comments on previous versions of this manuscript.