behavior analysis, ethics, preventative schedule, RAD, reactive attachment disorder, supervision in behavior analysis, trauma, trauma-informed behavior analysis
(Part 12 of a series of posts about Trauma-informed behavior analysis by Dr. Teresa Camille Kolu, Ph.D., BCBA-D)
If you’re a behavior analyst, perhaps you read that title as “Is it behavioral to treat reactive attachment?” or “is it appropriate to use behavior analysis with a person who has been diagnosed with reactive attachment?” Perhaps you are really wondering, “is there anything I can do as a behavior analyst to help someone who has been affected by reactive attachment disorder?”
These are all good questions. First, to pose the problem another way, and to see the depth of the controversy, let’s go over some other observations I’ve heard, from mental health therapists to educators to families to BCBA’s: “Behavior analysts shouldn’t mess with reactive attachment.” “Kids with reactive attachment disorder don’t respond to behavior analysis.” “Families (or educators) whose children (or students) are suffering after reactive attachment related diagnoses can be harmed by or mistreated if people use reactive attachment.” “Reactive attachment is not a behavioral term and shouldn’t be treated with ABA.”
Now if you’re a longtime blog reader, you’ll find other ways of addressing these questions elsewhere on this blog. (I especially like talking to educators, family members and staff about what to do when praise doesn’t work, reminding us all that behavior is INDIVIDUAL, trauma-informed behavior analysis might look VERY different than that old discrete trial program you saw in college, and behavior analysis is not one cookie-cutter bag of tricks.) But I continue to hear questions about it, especially from educators, family members, and hospital and day program professionals faced with supporting the “toughest” cases.
If you’re a behavior analyst, this paragraph is for you: I can’t say it enough, or leave it out, because there will always be a new reader who hasn’t heard (or absorbed) it. Although your training, mentor or graduate advisor suggests any behavior can be treated using behavior analysis, this doesn’t mean you SHOULD take any case. Please see the important caveats in the Ethics code about taking clients for whom you have experienced both expertise (see Ethics Code 1.02; 2.01) and supervision, and for whom you’re fully prepared to collaborate robustly with other crucial professionals. The same goes for supervisors: Do not offer to supervise such cases unless you are prepared and experienced (2.01; 5.01). Get your own before giving it to someone else. This can be life or death.
So what about reactive attachment?
Is it behavioral to treat it? Let’s start with what it means by “treat”, starting by contrasting what it does NOT mean. As a clinician, when I “treat” a person whose background includes life events and behavior patterns that are consistent with the diagnosis of reactive attachment disorder, it may help to look first at a few things I do NOT do. (Note: this is from my personal perspective as a BCBA-D, or doctoral level Board Certified Behavior Analyst).
I don’t diagnose.
If someone does not carry the diagnosis of reactive attachment (or any diagnosis, for that matter), I am not the final (or any!) authority on whether someone should add or remove a diagnosis. Rather, I can make and record observations about the person’s behavior, assess behavior and its relationships to the past and current environments, and plan related interventions. Some of these observations may be consistent or inconsistent with a diagnosis that is carried already, or consistent with my knowledge about the disorder, but I am not adding or subtracting diagnoses from the person’s record. Any data I collect is to help me understand how to help the person and their caregivers to have a more meaningful life, to use safer and more effective behaviors, to gain important social or communication or leisure skills, etc. (If you are interested in learning more about the diagnosis, you can check out this website: http://www.cebc4cw.org/search/topic-areas/dsm-5-criteria-for-reactive-attachment-disorder-rad/)
I don’t suggest I will “get rid” of a label.
Now sometimes, in rare cases, I will treat a client who has a diagnosis that is simply a cluster of “behaviors”, and this set of behaviors seem to happen less and less as a person gains functional skills that still get their wants and needs met, crowding out the old stuff that was the reason for a particular label. But in general, you are not seeing me because you want me to take away his “RAD” (or her “autism” or her “Rett syndrome” or her “hearing loss”). Right? You are seeing me because you want her life to be better, and for him to experience behavioral wellness, and for you to have a healthier happier relationship. I’m not here for the diagnosis, I’m here for the person.
I don’t treat alone.
I think, from my experience, that never has this been truer or more necessary, than in cases which are affected by reactive attachment.
Wonder why I say “affected by reactive attachment?” That’s because this label doesn’t come up only when a child needs treatment and that child has been diagnosed. No, it also comes up when a parent is struggling to parent their young children, and the parent themselves experienced trauma and loss and perhaps abuse and neglect as a child. If you did not have stable relationships when you first experienced having a parent, then being a parent and providing safe stable interaction over time might seem foreign at first.
Another way that it comes up is when I support a hospital or day program team whose client or patient has been labeled with this or a similar diagnosis. The caregivers are typically struggling with burnout, and the agency has lost one or more staff to the struggle. The hospital unit or agency faces the task of supporting the staff who are often walking back into a difficult situation (that may even be abusive, by some definitions) on a daily basis, working with the teen or young adult who has landed there after “burning out” multiple other placements and caregivers (and thus, experiencing loss of relationship after relationship).
So each person in one of these layers, from the client to her family, foster or adoptive parents, and all levels of agency or educational facility staff, needs some support that is informed about the unique needs of treating clients after this particular kind of difficulty.
Furthermore, most of the children or adults I see with RAD have a range of diagnoses. When I treat the environment surrounding a person affected by RAD (for that’s a better way of putting it, that I am engineering the environment to be supportive, rather than treating a behavior), I am doing this as part of a long-term partnership with several team and family members. The more the better. (By the way, I have found that social workers and educators are typically very interested in collaborating and when we expand and strengthen our team relationships, the client often has a better chance of getting “better”.)
Now for a few things I CAN do.
Hint: It involves teaching caregivers to be (or foster consistent interactions that are) the opposite of reactive: instead of being reactive, we must be both preventative and responsive, and do this consistently. This is something that I believe the science of behavior disciplines us to do.
As a behavior analyst, I CAN become fully informed about history.
This is not actually extra “stuff” or a burden; it is my job and my deepest responsibility (see Ethics Code 3.0). The past can inform the present and the future in important ways, and if I am doing a functional assessment, I need to know what behaviors happened, what kind of family history went on, whether the child witnessed or experienced violence or sexual abuse, and when and how they were moved from caregiver to caregiver. I need to know about a history of law enforcement involvement and trouble in school, starting from the earliest daycare to now. I need to find out whether the educational environment was a place the child escaped and excelled, or if it was another contributor to their problems and they lack fluency in foundational skills. I need to know if they had unmet or previously addressed medical needs and if their caregivers or siblings had chronic pain, mental illness or medical problems, or served prison time.
Caveat: I often get the question “what do I do if there is no history?” An upcoming post discusses some ways to move forward, but when possible we review documentation and history whenever we can, within the ethical boundaries of confidentiality.
I can help document risks and needs. I have written elsewhere about the need to document risks (see 2.09c, 4.05) and help collect data to help manage and mitigate them. In reactive attachment situations, there may be greater risks to caregivers and educators than in some other cases. As a behavior analyst, I can foster robust and ethical collaboration and regular conversation between the caregivers on the team. Some might be at risk of false accusation and emotional or other workplace challenges for which they are unprepared. The risks should be carefully documented and discussed without blame. This provides a venue for others to jot down challenging experiences to discuss later at appropriate times, and to discuss the installation of important safety features in facilities or homes. Preventative behavior plans that explain how to use safety features in the environment (which should be discussed beforehand with the client’s human rights committee wherever possible) can be included in client’s treatment plans to mitigate risks such as false accusations and foster important consistency between caregivers, while providing a plan towards greater independence within safe boundaries for the client.
A client’s story: Tammy was a 13 year old girl in foster care who seemed like a different person in front of her foster father versus her foster mother, and still a different person in her educational and hospital settings. Each caregiver seemed to bring out another “side”, and she made false reports skillfully and without seeming to notice it or care that her actions could land a staff member or parent in jail. If someone punished her, she often used angry vitriolic accusations, while behaving so sweetly in front of others (including the police) that they could scarcely believe the teacher’s (or her mother’s) report. After she moved to a residential setting, some staff within her educational day program setting seemed barely out of high school themselves, and had a hard time “accepting” or “not taking personally” her volatile outbursts, and would yell back or react in ways that resulted in her behavioral escalation. Her team seemed to be on 10 different pages when it came to how to respond to her demands, needs or challenges, yet nothing worked.
I can build communication maps for teams supporting a client with needs like Tammy’s. Before we do this, the team is often contributing without meaning to, to the client’s “team-splitting” behaviors. After we do this, there is a road map for when communication will take place, which behaviors should prompt a similar response from anyone on the team, and when and how preventative check-ins will occur and by whom, so the client does not have to “wait” for instability to produce a staff or family member “reaction”. Within the plan, there is room for how each member of the team will personalize the plan but still stay consistent with the function-based treatment.
Finally, I can collaborate to contribute treatment that is BOTH function-based AND history-informed.
As a behavior analyst, I am not the only member of the team. And I am not the most important member of the team! I need to partner carefully with the social worker, mental health therapists, psychiatrist and psychologist, caseworker, teacher, occupational therapist, parents, grandparents, auntie, and/or whoever is there (and who will be there in the future) for the client. In my experience, these additional team members are thirsty for compassionate and function-rooted procedures that will acknowledge their client’s history while also giving them action based tools. I have written elsewhere about the need to provide function-based treatment that is also fully considerate of the long-term or previous functions or meanings of behaviors; I am not suggesting that all behavior pays off only in the moment! In my clients previously diagnosed with reactive attachment, they are also responding in ways that reflect years of previous caregiver neglect, and suicidal and controlling behaviors that were modeled before the baby could even talk. Although not all behavior analysts are trained to carefully evaluate all the sources of behavioral or “reinforcement” history contributing to current behaviors and needs, some are.
In short, the management of behaviors consistent with reactive attachment diagnoses can be supported by a team informed by the ways behavior support could help foster consistency and communication. Yet we can still do harm if we fail to follow important ethical guidelines and seek appropriate supervision and mentorship before expanding our expertise in such a way. For behavior analysts interested in exploring this area, I encourage you to seek out an experienced mentor or supervisor in addition to receiving extra continuing education here. For educators and families interested in learning more, you can write a behavior analyst and ask about their experience and supervision in this area. Basic behavior principles are still helpful, even though your BCBA needs to be ready to do things differently than they did in their autism or early intervention cases. I have found my most rewarding collaborations with psychiatrists and social workers and families who embraced the challenge of meeting behavior and mental health needs on these sensitive cases. I have written elsewhere about the approach I take, which I usually refer to as engineering preventative schedules of interaction, or arranging a preventative environment. That’s because it all starts with teaching caregivers to be the opposite of reactive, as they learn to be both preventative and responsive. Learning to engineer a preventative schedule of interaction can be a valuable behavior cusp for a team or family member!