Contraindicated behavioral procedures after trauma

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This is the 20th article in a series on Trauma-Informed Behavior Analysis by Dr. Camille Kolu, BCBA-D

In medicine, contraindicated procedures are those that are withheld due to the potential harm they might cause to a patient. More and more, behavior analysts are interested in learning about someone’s history, in part to lessen the risk they will do a client harm.

We are tasked, ethically, to do no harm (and see the BACB Ethical and Professional Code item 4.02); to evaluate potential risks and side effects of interventions and to weigh the possible benefits of each (see 2.09 and 4.05); and to avoid using harmful reinforcers or those that require excessive motivating operations to be effective (4.10).  For RBTs as well as those certified at higher levels, ethics obligates us to protect our clients from harm (see RBT Ethics Code section 2.02).

In our live webinars (please see CuspEmergenceUniversity.com where we list topics we train frequently on– any course you see there is available as a live webinar training or, in some cases, available as an on-demand training), we receive frequent questions like this:

What kind of procedures should be avoided when working with a new client after certain types of trauma? Are there certain procedures we should give more thought to after a client has been through challenges we know about? What do we do if so?

Given these wonderful questions, today’s post shares a few basic procedures that may be contraindicated – at least at first—given a specific combination of historical factors involving trauma.

Of course, it’s not black and white. Often this should just be the first step for the team, a conversation in which people consider potential for risk conferred by historical variables. The team can then make a more careful decision in order to mitigate possible risks and maximize the benefit of any procedures selected, along the lines of what our code suggests in item 4.05. Though each procedure below is potentially contraindicated at first, it could be appropriate later in treatment, or perhaps from the beginning- the point is that this should depend on an individualized risk versus benefit analysis of the other options available to the team, the client’s history and needs, the severity of the past abuse or neglect or trauma, etc.

  1. For a client who has experienced previous food insecurity, food related abuse or neglect, and/or severe food deprivation:

One potentially contraindicated procedure is using edible reinforcers.

Notes: Here there are risks to the client, and also potential risks to the client’s relationship with their caregivers and team members. The conditions necessary to establish the motivating operation for reinforcement may be similar to previously neglectful or abusive conditions, or may act as conditioned motivating operations that make harmful behaviors temporarily more likely. In our history treating clients after these circumstances, we have also experienced something related to behavioral contrast in this situation. For example, a client who was provided edible reinforcement in their new applied behavior analysis setting then went home and used dangerous and surprising behaviors related to their neglectful history. The client’s foster family was caught off-guard by these new behaviors, but they could have been predicted during team education on how edible reinforcers might need to be avoided at first when conditioning new team members as reinforcing (and as instruction-related discriminative stimuli).  

2. For a client who has been involved in previous sexual abuse (including when the client also makes allegations):

One contraindicated procedure is assigning a 1:1 without additional oversight.

Notes: Here there are risks to both the client and additional team members. When the team receives this case, it would be contraindicated to immediately assign 1:1 support without preventative measures such as training for the 1:1 and supplemental recording, additional oversight or whatever is deemed necessary.

3. For a client who has experienced medical complications from sexual or physical trauma (e.g., this could include incontinence, fecal smearing or related concerns, etc):

One contraindicated procedure is conducting toilet training without oversight from a medical professional, additional training or consultation by someone with expertise in this circumstance, etc.

Notes: In this situation, respondent and operant interactions can occur that are dangerous to treat without expertise; the client can risk serious complications and worsening medical problems; there is a risk of further conditioning the experiences of voiding (and related rituals) as aversive; there is a risk of occasioning behaviors related to the past abuse, or pairing aversive events with team members involved in the procedures; and more.

4. For a client who has experienced previous neglect or adverse circumstances (such as deaths of parents, removal from unsafe conditions, or experiencing war, dangerous immigration or poverty related issues), resulting in deprivation of basic needs and social interaction:   

Some potentially contraindicated procedures involve attention related extinction, differential reinforcement of appropriate versus inappropriate requests, or time out from attention reinforcement.

Notes: In this situation, there are safer procedures to begin using that could avoid some of the harmful side effects of removing attention contingent on unsafe behavior. A child with a serious history of neglect may have used behaviors that can seem bizarre or out of context for typical child development, but that were critical to the child’s survival. At the same time, it may not be appropriate to pair new team members with procedures that were used in the child’s neglect, even if the “intent” is different. There are many procedures that can be used more safely, such as using enriched environments and fixed time schedules, to provide monitoring, insure high levels of safe attention, and begin to condition adults as neutral stimuli again, if needed, after harmful interactions with adults in the person’s past.

5. For a client who has been affected by physical and/or sexual abuse, behaviors and circumstances consistent with reactive attachment disorder, or multiple and changing caregivers in childhood:

One potentially contraindicated procedure might be contingent praise statements to establish compliance related behaviors.

Notes: In this situation, a client may have had a history in which adults could not be trusted, behaved inconsistently or inappropriately, or paired unsafe and harmful actions with typical caregiving behaviors. Clients who experienced this may initially present as lacking “a compliance repertoire”, but it may be contraindicated to attempt to establish and praise compliance, for several reasons. Some may be overly compliant, and lack self-help and self-advocacy repertoires that are critical to autonomy; if they are still going home at night after the school day to an unstable situation or multiple foster homes, to praise rigid compliance may increase the risk of further victimization or contribute to future abuse. At the same time, initial praise for compliance may damage relationships between the client and new caregivers who have not “earned” the right to praise the client’s behavior by establishing a history of consistency and helpful interactions. Furthermore, praise might already be conditioned as aversive for the client and could sabotage the caregiver’s attempts to establish a relationship or instruct appropriate behavior. (CuspEmergence.com has written elsewhere about praise here).

6. For a client who has been affected by neglect, and involved with law enforcement, suspensions and challenging behavior:

A potentially contraindicated procedure is least to most punishment.

Notes: Implementing punitive procedures (or procedures that educators assume to be aversive and are using to control behavior) in a “least-to-most” order is dangerous, especially after the interactions mentioned here. Any time punishment is implemented in a LTM order, we risk these outcomes: conditioning the aversive stimuli becoming more reinforcing, and more familiar; worsening the client’s behavior as they need to contact more and more of the supposedly aversive stimulus; pairing the people administering the punishment with aversive control, making it more likely the client will (to speak loosely) act out more and more for their high-quality attention; etc. (CuspEmergence.com has written about the potential pipeline from special education to prison here, in an article referencing some of these concerns and containing behavior analytic references.)

7. For a client with symptoms or diagnosis of trauma-related disorders or needs:

A potentially contraindicated thing to do is recommending or implementing applied behavior analysis without any mental health or trauma-focused treatment or input.

Notes: Behavior analysis (at least the kind I provide and teach about) is not a trauma treatment. We are also not a source of diagnosis for trauma. Instead, I work in a complementary way with a team and/or family that is interested in learning about risks related to trauma history, and how these risks affect the person’s behavior, needs, and supports. There are therapies that can provide trauma-focused treatment and aid a person to heal after experiencing difficult circumstances; a person may need these in addition to, or before, receiving behavior analysis to aid them in developing a safe, expanded behavioral repertoire. If someone trusts you with their trauma history, please be careful and supportive.

In closing, for a client with a specific conditioning history, the contraindicated procedure would likely involve aversive conditions and potentially medical or biological variables. Always consider items 3.02 and 4.08 from our Professional and Ethical Code, and discuss whether they apply to your case:

3.02 Medical Consultation. Behavior analysts recommend seeking a medical consultation if there is any reasonable possibility that a referred behavior is influenced by medical or biological variables.

4.08 (d): Behavior analysts ensure that aversive procedures are accompanied by an increased level of training, supervision, and oversight. Behavior analysts must evaluate the effectiveness of aversive procedures in a timely manner and modify the behavior-change program if it is ineffective. Behavior analysts always include a plan to discontinue the use of aversive procedures when no longer needed.”

Upcoming: Brief webinar series on TIBA in partnership with Connections-Behavior.com

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Now that the annual conference for ABAInternational is past (whew!), Cusp Emergence is excited about upcoming webinars and online conferences (New Hampshire and FABA, I’m looking at you!). First up is a partnership with Connections-Behavior.com: We will look at trauma-informed behavior analysis in two parts, on June 1 and 15. Register here for this CEU opportunity!

3 Simple Ideas: Teachers Check In on Families Staying Home

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Today as I online and supervised a special education teacher via a Zoom chat, we talked about her ideas and mine for teachers supporting special needs students and their families from behind our computer screens right now.

Note that she is doing a LOT. Families are doing a lot. And many teachers have families too and we’re all a bit swamped. Most of us are trying to practice grace- both giving it and operating from a place of grace ourselves, being easy on ourselves when we don’t finish everything… but it’s still hard. So here are 3 easy ideas that might make a difference. If you’ve done them, GREAT. Just move on. 😊 If you haven’t, it can’t hurt. If you have young children at home you can ask your kid’s teacher for a little guidance on the first 2 and they’ll probably be happy to help you out.

  1. Arrange the environment to help students understand what’s going on. Number 1 is to give parents guidance on “arranging the environment”. Something teachers do before school starts is to arrange the classroom. Ever notice that when you walk in your student’s room, that there are usually separate little areas? There’s an area for work, and it’s where your child learns to sit down and do learning activities. Maybe there’s a little table and chair there, and some baskets for papers or materials. Then there’s an area for breaks, which you can usually notice by its comfortable chair or bean bag or rug, and perhaps some books or games that are just for fun times. If you’re a teacher working with kids at home, ask families if there is a designated area for work, and one for play. Give families some suggestions that are easy and similar to what you do in your classroom. It’s easy but it can go a long way toward normalcy, helping students get ready to do their work, and helping caregivers and parents help their kids get in to the new routine.
  2. Send home important visuals, or give a really quick tutorial on how to create one.  I’ve been surprised by how sometimes therapists and teachers forget that they always have a certain thing on the table that reminds students how to sit, listen, or be a part of the classroom. Maybe you feel it’s not that important at home, or that it’s just more work. But students really thrive when you help their learning behaviors to “generalize”… by putting things in the environment at HOME that they are used to seeing at school. If your school has a simple visual schedule or job aid that reminds students what to do with their eyes, hands, body and mouth while it’s “time to work”, send it home. Parents can even draw one with markers or crayons if they don’t have a printer. Now’s not the time to get too fancy or require too much. In behavior analysis we might call this “programming common stimuli”, when we use a helpful reminder across environments. But it’s just a super simple tool you have that you can give parents during your check-in or start-up session.
  3. Do a check-in with parents/caregivers every time you see the family. Some teachers are having groups with students, which is amazing. You may also be doing quick individual check-ins. A few days ago I wrote about how child abuse and neglect are escalating right now, as families are facing increasing pressures and hardships from all sides, and the typical “reporters” are not seeing the kids in person to make social services calls. (It’s a great time to learn more about what your school can do to help teachers develop a process for this). One simple idea is to have a quick script you go through every time you make contact with a caregiver, especially one of a family you know is always at risk. Put THREE THINGS by your computer: First, put the script by your computer. Second, put a simple datasheet there beside it. (A simple datasheet might include the list of families you contact, dates you ran through the script, and star any families you need to follow up on based on the outcomes of the script. Then when a family answers a question that needs follow up, you can share referrals or make a call to connect them to a resource). Third, put a list of resources and phone numbers related to the script questions. These might need individualization based on your area, but here are some ideas.

Example of using the check-in idea:

Margot is a teacher of special needs kids in elementary school. She writes a script with questions like this: “How are you doing? … What is most concerning to you right now? … Do you have at least one way that you can get a break when you need it? … Are you worried about where you might get food? … Are you feeling ok emotionally or do you need someone to talk to? …  Is there anything your child is doing that you think needs a follow up phone call? …. Is everyone in your family safe right now?”  

Then Margot shared the script with her team and each teacher and paraeducator was assigned one family per day to check in on. The team brainstormed and wrote a list of important phone numbers and websites in the event that a family indicates they need basic assistance like food; they are feeling extra stressed and need a mental health support check-in with a teletherapist; or someone in the household is hurting them and they need to make a phone call to a domestic abuse hotline.

Finally, the team distributed a quick reference sheet with the script on top, a log in the middle, and resources (phone numbers and websites) on the bottom. Each team member recorded the results of their check-ins in case follow up was necessary to help a family they checked on.

That’s it. You can see an example Check-In and Follow Up Log sheet below. Let me know your own ideas and thank you for all your hard work! And just email me if you’d like to obtain an editable version of the sheet.

Homebound and Vulnerable: What will you do to prevent abuse and neglect?

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This is the 19th article in a series on Trauma-Informed Behavior Analysis by Dr. Camille Kolu, BCBA-D. Start by becoming informed; then please read to the end if you’re interested in taking steps with your organization to support therapists and teachers to continue to fulfill their roles as mandatory reporters.

Child abuse, elder abuse, domestic violence, and abuse of people with intellectual disabilities is going on all around you. It may have just become simultaneously more prevalent, invisible, and insidious.

For example, in some areas, there has been a marked decrease in calls to the hotlines that typically lead to welfare checks for vulnerable people in their homes to insure that families have resources they need, children are not being abused or neglected, and appropriate actions can be taken if they are. (See this story from Colorado reporting a drop in calls the 9th and 10th of March as schools began to close).

Across the nation, different states are reporting similar decreases in calls but also a spike in the number of serious child abuse hospitalizations and even deaths.

Reasons for this disturbing increase are numerous. Little annoyances become big ones when there is no possibility of a break and both mental health (e.g., patience) and physical (e.g., food and sleep) resources are running thin. Even a normal battle on whether your kid will eat the peanut butter sandwich becomes a crisis when you’re trying to feed several people a balanced diet with whatever dwindling foodstuff you still have in the cabinet, while money (and outside trips) become scarce.

For many families, the struggle is not only real but getting uglier by the day, by each hour the kids are home from school.

There is conflicting advice, some of it really unhelpful, yet most of it well-intentioned. (I read a recent article about how we should just give in and let kids watch endless videos during this unprecedented time; but for many children, a huge increase in access to media may be accompanied by major behavior challenges (and even injurious and aggressive behavior) when parents try to have them turn it off for meals or bed. Research shows increased screen time can cause impulsivity, hyperactivity, and inattentiveness,

all of which are even more difficult to deal with when you’re cooped up. Of course, you need solutions, and the quick fix is even more appealing right now.

And there are major barriers to resources. Some have said this crisis is leveling the playing field, but really, it’s revealing discrepancies.  

Being quarantined at home doesn’t hurt that much when there’s plenty of food, you already know how to navigate technology to work from a home office, and there is room and time to get away from housemates or family members for a little while.

Being at home with other people who normally require 7 to 9 hours of behavior support and school-provided structure, let alone meals, while you work to make ends meet—that is another story altogether.

So there are the struggles to which we can all relate, and then there is the reality of jumping into these struggles with no help, no end in sight: There is the reality of suddenly not being able to be by oneself for even a minute, and not knowing when it will end; there are children whining or crying (or hurting themselves while other things need their caregiver’s attention; there is behavior, so much behavior, that a parent doesn’t know how to handle and is made worse by a lack of structure, suddenly upended routines, and for some, the complete loss of safety figures.  At the same time, there are abusive people who are now alone with their victims for the next few weeks.

Maintaining a safe environment for a child depends on several behavioral and environmental factors. Right now, those factors are not all present. Instead, we have

-Caregiver behaviors that are really important to keep people safe, but may not be FLUENT (such as giving effective instructions to a child, creating a schedule for several people, or responding to unsafe behavior that you usually don’t have to respond to)

-Caregivers that may physically present, but not AVAILABLE (e.g., an adult who can provide continuous, adequate supervision to every single member of the household who needs it)

-The presence of new circumstances creating unsafe environments (such as having 3 children with special needs home at the same time, for hours and days on end, and without the things (therapies, bus drivers, respite workers, social outings and educational time) that typically provide structure and relief)

-The additional presence of huge stressors (the unending flow of news about the virus; the dwindling of food and resources; the loss of jobs)

-Competing, sometimes incompatible, needs (like people home from work who need quiet to make money but who also have to provide constant caregiving and supervision; or people who have intellectual and other disabilities and are without their scheduled programs, events, therapies, social opportunities)  

-Therapists and teachers who are working from home or not at all, but who normally document and relay evidence that a child or adult may be being abused, mistreated or neglected

These factors and more combine to produce

-The occasion for more abuse or neglect to occur

-Decreased opportunities for abuse to be reported

-Emotional and physical needs that may make the outcomes of a child being quiet or following directions suddenly much more important or reinforcing, whatever the cost

So, my therapist, day program provider, and educational staff friends- how will you add and document safety checks for all your clients on a reliable schedule to take the place of “having eyes on” the client in your clinic, their home, or your school or program?

There are no hard and fast answers. For instance, some behavior analysts are out of work; could they be repurposed to providing online support of families with children at home? Having eyes on the family is good, but it’s also introducing a risk that we will give advice that we don’t have an assessment to back up, or that is not fully safe to implement. And while I’d like to share ideas for behavior analysts to incorporate safety checks of your clients virtually, it’s most important for me to encourage you to reach out, right now, to your organization—and ask for your TEAM’S plan to do that. This is because different states and areas have different guidelines and requirements for you to follow depending on your local recommendations for HOW you monitor and report unsafe situations. You need to do it, but you should follow your local guidelines and state laws.

  1. Recommit to your role as a mandatory reporter for individuals with disabilities, the elderly, or children, if you are a therapist, teacher, etc.
  2. ACT as an employee: If you work for an organization, act by asking your company what their contingency plan is for all employees to fulfill this role given our emergency situation, and how you can help.
  3. ACT as an employer: If you own or lead an organization, stop right now and generate a brief plan for how you’ll support your team to fulfill their roles as mandatory reporters. Here are some ideas:
    • Write up a plan and email it out. Bonus points if you schedule an online meeting right away to disseminate it and give examples and encouragement.
    • Assign everyone a recommended frequency to make check-ins that specifically deal with the client’s physical well-being and mental health.
    • Give the team an example for what questions they can ask, and what they should avoid (if needed) to maintain everyone’s safety in the home they are looking at.
    • Tell employees to document the outcome of their checks (e.g., if they notice things that typically would indicate possible abuse or neglect; or if they notice something might be wrong that warrants another check-in from a supervisor on your team; if calls are made to CPS or APS)
    • Reinforce and encourage the behavior of employees who follow the plan, including having social support carved out for them so they don’t have to go it alone.

Telehealth provision is already a new skillset for some employees, including teachers, and if they are suddenly without any social support when they used to be able to walk down the hall to the counselor, administrator or psychologist on site, they may freeze and wait when action is important. It’s your job to make the unfamiliar but correct action as easy and supported as possible.

And here’s a notice: Social services haven’t closed down. In Colorado, not only are they still making visits, they are hiring. Hotlines are available and staffed with trained professionals to take your call.

Resources: Read guidance from the Behavior Analysis Certification Board on ethics, safety and more related to Covid-19.

Here’s more on how a few states are monitoring this issue.

Colorado:

Call 1-844-CO-4-KIDS if you suspect abuse or neglect

https://www.coloradocac.org/

For birth to 3 receiving services: http://coloradoofficeofearlychildhood.force.com/eicolorado/EI_QuickLinks?p=Home&s=EI-CO-Response-to-COVID-19&lang=en

Ohio: https://www.cleveland.com/court-justice/2020/03/staying-at-home-amid-the-global-coronavirus-pandemic-creates-new-dangers-for-victims-of-domestic-violence-and-abuse-experts-say.html

And in Texas, use this info:

https://www.allianceforchildren.org/

If you suspect a child is being abused or neglected, please contact the Texas Department of Family and Protective Services toll free at 1-800-252-5400, 24 hours a day, 7 days a week.

You may also file a report using the secure TDFPS website. Reports made through this website take up to 24 hours to process.

The Texas Abuse Hotline is 1-800-252-5400.

Connecting Behavior Analysis, Aging, Trauma, and Supervision

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Behavior Analysis, Aging, Trauma, and Supervision (or BATS, in honor of Dr. Janet Ellis).

This is the 18th article in a series on Trauma-Informed Behavior Analysis by Dr. Camille Kolu, BCBA-D. It includes something new that we have been asked about: Companion notes for students and supervisees working through this information with the support of their supervisor.

I heard Jon Baker give a great talk on advances in behavioral treatment of gerontology the other day at COABA. It made me think of my students at the University of Colorado Denver and our supervisees. (There was also a fantastic talk on supervision and feedback by the incomparable Ellie Kazemi, whose book on supervision is out now). When they ask about clients other than autism who have benefited from applied behavior analysis, my supervisees are usually excited to read stories in which ABA changed the lives of people with dementia, brain injury, medical needs, and more. For example, an article from Baker (2006) Continue reading

Seeing Snakes and Spiders

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This is the 17th article in a series on Trauma-Informed Behavior Analysis by Dr. Teresa Camille Kolu, Ph.D., BCBA-D.

spider

What did you do when you saw this picture? Chances are you experienced some additional events beyond just “seeing it”. Did you jump? Experience an increase in your breathing rate? Use some choice verbal behavior? Avert your eyes? (And are you prepared to read on? Fair warning… there’s a snake coming up).

Seeing with fresh eyes

I noticed a couple of things about our culture, and fear responses, this past week.

My young daughter’s love for flap books—the kind where you pull back a piece of paper to reveal something—knows no bounds. So she was instantly drawn to a tattered old library copy (apparently she shares this love with lots of peers) of “Buzz Buzz, Baby”- with poorly rendered babies exploring “bugs”. Around the third page the baby pulls back a web flap to unveil, in the book’s words, “EEK! The itsy bitsy spider!”

Whenever I read the book to her I leave out the “Eek!”.

I think she can come up with that on her own, if she happens to, although chances are she’ll get it from me in a non-mindful moment. (In the 1980’s Cook and Mineka did a classic study in which infant monkeys “acquired” a persistent fear of snakes by watching their scared mothers encounter a snake).

Now that we’ve moved out to the country, we encounter our own “Itsy” (and many for whom that name is woefully inadequate) all the time. (I do recommend this thing called the BugZooka… it does work really well, if you like catch-and-release). Itsy and I go way back, and not necessarily in a good way, although I always appreciate her beauty. But I still want to be warned before you text me her picture, dad.

This summer, one tenacious spider (pictured, top) built a web, over and over, in a windy area outside the kitchen, where we see it numerous times daily. The first few (ok, few hundred) times I nearly jumped out of my skin. When I remembered in time, I was very careful to breathe and compose myself before walking to the sink with my daughter, where I’d point out the spider cheerfully and sing (with all the hand movements) the requisite song. Before long she was signing the song herself. Next I noticed myself no longer jumping when I saw the spider.

THEN… one windy morning Itsy was gone. Gone!

I didn’t breathe a sigh of relief.

I was surprised and curious to feel a strange emotion… like MISSING. I missed her! Was she alright? Would she come back? (She was. She did).

With painful awareness that this is temporary, I often marvel that my daughter’s eyes are not only young… they are unconditioned. They don’t have a lot of pairings with events like scary movies about this deep primate fear, being bitten, or seeing spiders while a parent jumps and screams. They are fresh, curious, hopeful eyes.

Yesterday we chanced upon something rather larger than even the biggest spider. It was this old girl… fat and long, with ring upon ring adorning her useful brown rattle. Depending on my readers, maybe you’ll be happy that instead of grabbing a hoe, I called a guy I read about in my new community’s online forum… apparently this guy LOVES snakes. “ANY snake’s worth my time”, he told me as he jumped in his truck. 35 minutes later he had driven up to our homestead, hooked it and taken it. Now it’s in a quite different rattlesnake heaven than the kind I had sort of planned to send it… blissing out in a protected wilderness area up near Fort Collins, I’m told.

rattler

As he removed our snake into a large vented box and curiously counted the rings (while remarking on how huge it was), the guy’s face was composed; he exuded a strange calm excitement. Normally, the fear response to snakes and spiders is part of our biology. Evolutionary biology has several theories why it’s present even in infancy, and why it might have behooved our ancestral mothers to experience more arousal and get out of there to protect their young in the presence of these critters. I can’t help but wonder what this guy’s history is like. Why does he love something that most of us are scared of?

Kids with traumatic histories

If you’re an educator going back to school, many of your kids are coming in with an avoidance response, or a “get out of there!” escape response, ready to go. Some of them will use these responses in the most annoying ways, dropping all their work on the floor or crawling under desks when you announce the quiz. But some of them have a special background you can’t see. For some, they will use these “fear responses” when they encounter “triggers” that you and I do not think of as scary.

Why is that?

Well, the things that were there when they experienced really bad situations are now “paired”, living together in their past, the same way I smelled an old lady yesterday wearing my own granny’s soap and got emotional thinking about my dear departed loved ones. Or the same way you hear a certain song from your high school dance and think about that year, or that person, or that kiss.

And that’s not all. Psychology explains in anxiety journals why, if you’re a person with an intense “fear” or phobia of spiders, not only do you spot them more quickly and tend to see them where your peers might see other things, like mushrooms or flowers faster in the SAME PICTURE—but to you, they also appear BIGGER.

What can we do about it?

How can we help students show up for their education and get all the learning opportunities they can… even when the school, teachers, and peers accidentally give them “fear related” stimuli all day long? (While psychology explains partly WHY these pairings happen, behavior analysis does too, especially if you read some relational frame theory, learn about respondent conditioning, and take a long-term functional analytic approach. Behavior analysis also goes a long way in helping the helpers undo some of the damage, teaching kids to approach adults and “unpair” adult attention from it’s previously bad parts: if I’m a student who has been through neglect abuse, my teacher coming over to me to praise my “good behavior” might not be a welcome stimulus at first… and my teacher’s praise, as well-intentioned as it may be, might not work).

Cusp Emergence University has been hard at work getting the new online training course ready for educators, and behavior analysts who work in education. We hope to help you to start answering these questions for yourself and your students and teams. On Monday, September 30, our course “Education and Trauma-Informed Behavior Analysis” opens to a 7 day sale (use the code EDTIBA10 for 10 percent off this CEU opportunity). We’re providing BCBA’s and BCBA-D’s with 3.5 continuing education credits, and 3 of those are in ethics.

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Sign up now!

Start your fall to-do list: Register now for Paradigm play webinar this Monday (and more)!

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This summer has been a busy one for Cusp Emergence. Dr. Kolu taught Ethics to University of Colorado Denver students, jumped back into work doing consultation to support businesses and BCBA’s to reach their behavior analytic goals, trained CASA volunteers and more. Next month we will be training Friends of Broomfield and (finally!) putting the finishing touches on the Education and Trauma Informed Behavior Analysis course by Cusp Emergence University.

In the meantime, we just learned about a great low-cost resource for parents! Paradigm Behavior has all kinds of great parent-oriented supports that also help behavior analysts and caregivers. This Monday they are having a sale on an informative webinar!  REGISTER HERE:

https://paradigmbehavior.com/play-registration

You know who would also benefit from this? Foster and adoptive parents, preschool teachers, and church nursery staff would find this super helpful. Our trauma informed teams also love learning how to enrich “time in” with kids who are just learning to have fun with adults in carefree ways after a difficult early life.

And coming up, this fall we’ll register for the APBA (Association for Professional Behavior Analysts) convention coming to Denver 2020, attend COABA (Colorado Association for Behavior Analysts) on November 2,  sign up for 4CABA (Four Corners Association for Behavior Analysis) that meets in Colorado Springs April 2020, and submit proposals for the May 2020 workshops at ABAI (Association for Behavior Analysis International) in DC. We’ll be back shortly to tell you all about the new courses we’re offering this fall. Contact us today if you’d like Cusp Emergence to tailor an online workshop or training for your team. Hope to see you soon at a local event or meet you at one of our webinars (CEU’s offered at all of our events)!

 

“Trauma-Informed Behavior Analysis” is redundant. Here’s why I use it anyway.

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“Trauma-informed behavior analysis”: Redundant term or useful phrase?

This is the 16th article in a series on Trauma-Informed Behavior Analysis by Dr. Teresa Camille Kolu, Ph.D., BCBA-D.

Trauma-informed behavior analysis, abbreviated TIBA, is a phrase I’ve been using for a few years now to describe what I do to people outside behavior analysis. I do this because it helps them to understand how I apply the science, and not to suggest that “regular” behavior analysis should not address trauma. From those behavior analysts who have not been to my trainings, I often hear the question “Isn’t it redundant to describe behavior analysis as trauma-informed?” I would argue that the short answer to this question is “yes”. However, this article describes why the more important and longer answer is “yes—and it’s still useful”.

About this outline: As one of our current projects at Cusp Emergence, Dr. Camille Kolu is aggregating several years of data (including feedback from existing BCBAs, educators, foster parents, and social workers) in writing a set of articles on the topic of applying the science of behavior analysis to behavior change after a person has experienced significant trauma. This topic comes up frequently on behavior analytic forums. Please note that this brief outline does not describe the SAFE-T model (by which we advocate appropriate supervision, functional assessment, risk documentation, and environmental modification and training) or solutions to all the challenges it raises. Check out the other blogs on this topic, email us if you’d like to provide comments and questions, or see cuspemergenceuniversity.com for CEU and training opportunities.

Background: How is “trauma-informed behavior analysis” redundant?

I. The ethical practice of behavior analysis already requires it.

  1. We individualize (see BACB Compliance Code item 4.03)
  2. We should practice within our expertise (1.02)
    1. People whose lives are changed by major traumatic histories are changed in ways that distinguish them and their needs for specific supports, much like people who engage in serious self injury or have eating disorders are distinguished as a sub population who can benefit by specific expertise and training. We accept clients only if we are appropriately trained (2.01)
  3. We are already tasked with taking history into account, including analyzing functional relationships (3.01) and referring to consultation for medical needs as appropriate (3.02)
  4. We should refer and collaborate when needed (2.03a and 2.03b)

II. The application of behavior analysis already covers it (see Baer, Wolf and Risley 1968, 1987)

  1. Appropriate ABA tackles behavior of meaningful social significance, which it (behavior that is related to historical traumatic or aversive events) certainly is
  2. Appropriate ABA is conceptually systematic, and treatment of behavior after trauma may be conducted within the conceptual basis of behavior science
  3. We already have interventions that can be applicable and effective with this population (see our resources page for a partial reference list) including treatments for post traumatic stress disorder, using acceptance and commitment therapy principles from behavior analysis, and schedule related procedures including NCR for challenging behaviors; or see Fahmie, Iwata and Mead 2016; Iwata, Petscher, Rey and Bailey 2009; Richman, Barnard-Brak, Bosch and Abby, 2015)

III. The underlying science of behavior analysis and work on learning and behavior already describes phenomena related to behavior after trauma (see literature on reinstatement, contextual conditioning, respondent behavior, extinction in multiple contexts, etc)

  1. Laboratory work on extinction challenges from a respondent conditioning perspective can help us understand some of the unique challenges people face after experiencing trauma (see Bouton 2004)
  2. In basic research, “renewal” (return of behavior that was previously extinguished, after exposure to a conditioned stimulus- see Bouton and Bolles 1979; Harris 2000) is stronger with respondent behavior than operant behavior (Crombag and Shaham 2002)
  3. But younger behavior analysts may not have been trained to adequately appreciate respondent conditioning’s effects on behavior, and to teach others how to work with behaviors that are not operant. They may over-rely on using consequences to change behaviors, leading to criticism that “this stuff doesn’t work with my client impacted by trauma”. (Respondent conditioning is an item on both the 4th and 5th edition task lists, although respondent-operant interactions (see 4th edition, item FK-16) has been removed).

The current state: How is the phrase “trauma-informed behavior analysis” still useful (even needed) if it’s technically redundant?

I. I believe it’s helpful to both practitioners and client base.

  1. For practitioners: widespread practicing out of expertise incurs huge risks to clients, agencies, individuals and communities.
    1. Many people assume that the application of behavior analytic principles to trauma affected populations requires no nuances, and have harmed others
    2. There are not widely available risk assessments and tools to help those of us in this subarea document and collaborate as effectively as we need to
    3. There is not a collective understanding of how the collaboration can work, and many behavior analysts proceed unethically (although unintentionally)
  1. For clients: People needing the service are thwarted by bad (or just uninformed) press about ABA or and many think that ABA would be ineffective, harmful, or contradictory to their trauma-informed colleagues’ practice. This phrase gives me a way of introducing my services and assuring the recipients that I
    1. will, and do, consider their history of trauma as something that informs everything I will do for them
    2. will still be practicing behavior analysis, but from this specifically informed perspective
    3. honor both their specific background and their individual needs, using my own training and expertise in behavior analysis informed by additional experiences with social workers, those in the foster family community and others

II.  This phrase also gives me a way in, to talk to groups who haven’t had good experiences with behavior analysis

  1. including professional educators, school psychologists and therapists who have attempted collaborations that failed because clients’ trauma was overlooked or the practices were ineffective
  2. and including foster and adoptive families for whom the practice of “everyday ABA” included go-to strategies that were not (or at least not at first) helpful to their clients
  3. or people who haven’t had ANY experiences with behavior analysis (in my practice this includes people from these groups):
    1. Lawyers and courts
    2. Court appointed special advocates
    3. Social workers
    4. Trauma therapists
    5. Foster families and adoption agencies

Dreaming of the future

My goals include that one day in the near future,

  1. Treating behavior after trauma is a specialty in which behavior analysts can readily obtain experience from several field experts, similar to how they gather expertise specifically in treating behaviors such as severe self-harm, pica, or disordered eating, or behaviors in people with autism or genetic differences, or those in pediatric or geriatric populations.
  2. For recipients of behavior analysis, it will be simple and easy to find several options for treatment for behavior after trauma, from people with appropriate understanding, training and supervision, that can help them and collaborate effectively with other members of their team
  3. There are multiple funding streams to readily serve the population (examples: foster care, social workers, etc)
  4. And “everyday behavior analysis” is no longer viewed as contradictory to the support that would benefit people with historical experiences described as traumatic

Takeaway: I agree that saying behavior analysis should be “trauma-informed” can be redundant, since the basic science is rigorous enough to describe why our behavior is changed after and challenged by trauma. But I use it because it helps communicate what I do to people who have a specific history, and to help other behavior analysts understand how to establish an ethical approach to the intense documentation, risk mitigation, collaboration, and assessment that is required while using existing behavior analytic procedures to support those affected.

What’s your take? Send me a note or share a resource any time.

See or add to our growing reference list related to behavioral treatment of trauma.

Beauty and the Bug: Trauma and individuals who are differently abled

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Beauty and the Bug (in which we briefly explore trauma and non-neurotypical people, ask how to raise tender-hearted children, and see a bug portrait in pointillism)

This is the 15th article in a series on Trauma-Informed Behavior Analysis by Dr. Teresa Camille Kolu, Ph.D., BCBA-D.

How do we teach others to tend the needs of those who cannot express them (or for that matter, appreciate the lesson of loss, the tenderness of pain, the beauty in brokenness)? And how common is trauma in individuals with serious developmental disabilities? Many of us have not considered the relevance, let alone the prevalence. Is this because we can’t see it, don’t hear about it, or think that it is out of our scope to address? These questions occurred to me this week as I thought about a participant from a recent training I provided, who asked if the model of trauma-informed behavior analysis (about which I’ve been writing here) applied to individuals with intellectual differences (it does!). Even to us professionals in the field of behavior analysis, the complexity of and subtlety of trauma and behavior remains elusive.

This week my family lost a wonderful man. He and his wife tended to the needs of others (often before their own). Also this week, my reason for taking a work break turned three months old, and Imagine! (a nonprofit agency in my area) had its annual celebration. As I mulled over these questions about trauma and differences and on raising good people, a therapist friend posted Imagine’s video of one of their clients. I realized I had not blogged before specifically about treating challenging behavior in someone who is differently abled. I need to do that, lest one more reader think that this approach (trauma informed behavior analysis) is mainly useful for “vocal” clients, or those who can easily articulate their pain and past. Today, Shelly and her zany personality inspired me to do this.

Individuals with developmental and intellectual differences express or show their history and needs in different ways, and sometimes caregivers overlook the contributions and signs of trauma, neglect or even ongoing abuse. When we (especially behavior analysts) overlook these, we are not addressing the real reasons for challenging behavior, and we might miss the importance of connecting the person with critical mental health resources, or of offering a chance to heal past wounds. We know about functional communication training. But do we fully address subtle needs to communicate pain—both emotional and physical? And when someone lives in an environment or is exposed repeatedly to a situation or person that is aversive (even abusive!) do we teach them to effectively advocate for removal and communicate their discomfort, or do we merely try to reduce the “challenging behavior” that often accompanies the terrible situation? Do we recognize the signs of abuse in individuals who have few skills to communicate?

Too many times, I took a case where team members requested decreases in “challenging behaviors” in someone with diseases like Parkinson’s, Alzheimer, or Spina Bifida, before the team had recognized that the main thing challenging about the behavior was that it was going on because the individual had NO dignified way out. A conversation with a peer last week revealed that without training in these issues, a behavior therapist or even the entire team might treat “suicidal ideation” as a “behavior to be decreased” rather than a serious problem to be solved. (Even when this “behavior” is partly a habit the person has learned to use as a tool to produce needed attention from others, a whole behavior analysis of the situation would consider the risks and possible outcomes of addressing it in different ways, and document and address the related needs to understand and address why this was happening.)

As Shelly and her team alluded to in the video, the very state of not being able to communicate one’s needs and preferences can be traumatic in itself, and can lead one to develop desperate behaviors that just get called “behaviors for reduction” in the individualized behavior plans of thousands of clients. Today there are no more excuses for not helping someone access and master a communication system that works for them. To be sure, not everyone has access to a Smart Home residence decked out with all the tools we saw on the video- but have you seen the article on an accessible app developed by the brother of a man with autism in Turkey (so that he could communicate needs  and gain leisure skills using only his smartphone)?

Tragically, many of my clients went through abuse and neglect and need someone to write careful and informed behavior plans that teach them skills they did not have at the time, like articulating emotional and physical pain, advocating for their needs, and requesting to be removed from a serious adverse situation. Just as important, these clients need an informed analyst who designs ways that these skills will persist when the client moves environments, as I found when a former client kept being exposed to new team after new team that didn’t read the plan and failed to recognize the communicative intent of the behaviors, and the medical component to the “challenges” the team demanded to be decreased. This calls for TIBA or trauma informed behavior analysis (if the team is not already using it).

So it’s not enough for our clients to learn these skills one time. The people who make up the audience, the environment, must respond enough to maintain them. If I ask for help and you respond no, why would I ask again? Remember the lessons of the family whose school team actually discouraged them from using “saying no” as a goal for their adolescent girl with autism, arguing that they didn’t have the resources to deal with her protesting all day long. Actually, the opposite is more likely to be true—that when our “no” is respected (listened to the first time), its use will be more limited to situations in which the person really “needs” it.

So back to my original questions. How do we raise little ones who are likely to grow up to appreciate and shape the voice of the voiceless, who honor the needs of people in ugly situations, who see the beauty in what others view as broken or beyond repair? How do we insure people will have the internal resources to value what isn’t immediately perceived as “valuable” by the culture? Maybe it starts when they are little, in modeling ways we can accord dignity to the frail, the elderly, the dirty. We cultivate tenderness as we show them we appreciate the spiderweb (AND the spider), the weed and its flower, the worm (thanks, mom and dad, Nicolette Sowder of wilderchild, and my very first client who taught me that not being able to talk is not the same as not having anything to say- click here to learn about Rett Syndrome).

Thanks to mom and dad, I still notice bugs and their beauty. I thought this one was wonderful when I looked closely, so I spent even more time to study and draw him. I thought he became even more beautiful as I continued to look. Maybe you can see his beauty too.

edh

Colorado Potato Beetle by Camille Kolu (c) 2018

P.S. There is so much trauma in our schools today, whether you work with students who are “typically developing/ neurotypical” or those with intellectual, developmental and physical differences. Don’t miss the next course from Cusp Emergence University on trauma informed behavior analysis in the educational setting (complete with CEU’s including one for ethics).

Some references and resources

CuspEmergenceUniversity

Articles on prevalence of assault and ACES in individuals with developmental differences:

https://injuryprevention.bmj.com/content/14/2/87.short

http://www.cfp.ca/content/52/11/1410.short

https://www.acesconnection.com/fileSendAction/fcType/0/fcOid/399727599841302176/filePointer/399727599841302363/fodoid/399727599841302361/ACESandDevelopmentalDisabilitiesSteveMarcal.pdf

Read about Imagine! Smart Homes: https://imaginecolorado.org/services/imagine-smarthomes

Watch Shelly’s story: https://video.xx.fbcdn.net/v/t42.9040-2/51213666_2064787060269873_328394071330521088_n.mp4?_nc_cat=110&efg=eyJybHIiOjMxMSwicmxhIjoxMjA3LCJ2ZW5jb2RlX3RhZyI6InN2ZV9zZCJ9&_nc_ht=video.fads1-1.fna&oh=79aed874369dc8f2ab3a3cc89efdd34c&oe=5C4F807E

Read about the man who developed an app for his brother: https://www.bbc.com/news/av/stories-47001068/how-brotherly-love-led-to-an-app-to-help-thousands-of-autistic-children

https://imaginecolorado.org/

Get the full TIBA (trauma informed behavior analysis series): https://cuspemergence.com/tiba-series/

 

CEU stands for Cusp Emergence University!

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Need training for your team in trauma-informed behavior analysis? Cusp Emergence University has launched! 

Come check out the site, sign up for one of Dr. Kolu’s courses, or just have a look around.

While we’re beta testing, save 15% on 3 CEU’s in a 2.5 hour continuing education course (Introduction to the Ethics of Trauma-Informed Behavior Analysis).

This course is for intermediate audiences interested in learning more about the ethics of trauma-informed behavior analysis, or using behavior analysis to provide responsible, evidence-based and sensitive support to individuals whose backgrounds include early or serious adverse experiences. Take this course to prepare your practice and team and plan for the increased risks associated with this population. BACB certificants receive your certificate upon completion of the course, which includes quiz questions to help keep you engaged. Course includes 2 ethics CEU’s.

DISCLAIMER: Dr. Camille Kolu of Cusp Emergence is a Behavior Analysis Certification Board (BACB) approved ACE provider. Advertisements for new continuing education opportunities (per the board requirements) will often be placed here. Check cuspemergenceuniversity.com for the full details, to enroll in courses, or to learn more about the continuing education opportunities provided.  The BACB does not endorse any individual courses.

Come back to the tab Cusp Emergence University, or check out CuspEmergenceUniversity.com  any time for updates on courses in development.