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) introduces us to an elderly elderly woman in a nursing home, whose team used functional analysis to find effective treatments for her aggressive behavior. This allowed her to complete a personal hygiene routine with more dignity and eliminated her having to be restrained, together with reducing staff hours prompting the completion of daily routines. Many of my students begin their supervision experiences without thinking of how behavior analysis applies to this woman’s population (or how we all end up there someday). But so did mine. Although I began my career 20 years ago in autism and early intervention, this past few years has involved many adult clients in nursing homes, mental hospitals, community residences, and medical facilities.

We talk in our introductory class about how an applied behavior analytic intervention must meet rigorous standards established not that long (nearly 50 years) ago. Our field is still new, our ethics code always being revised and updated. And new students are often surprised that an applied intervention needs to meet ALL the dimensions of ABA… not just some of them (Baer, Wolf, and Risley, 1968, but see Critchfield and Reed, 2017). Looking again at a client who struggles completing her bathroom routine multiple times a day, when sometimes it takes 4 to 5 people (who often get injured themselves during this physical support), isn’t it important to address the source of those struggles? Isn’t it critical that the intervention be effective, technologically described so her staff can actually do it, and consistent with our scientific body of literature and drawn from interventions that WORK (conceptually systematic)? Intervening on this topic by changing observable behavior is obviously socially meaningful to the person and her staff, and they need to use procedures and processes with generality, that work across people and settings. We need to be analytic, too, to individualize an intervention just for her, measure what she used to do and see behavior change that is caused by our intervention, so we know that it’s working before we program for generalization across all the staff and settings that affect her.

I thought about these two things- the application of behavior analysis to needs in aging, and the need to assess and program in ways that fulfill the dimensions of ABA – when talking to New Hampshire Association of Behavior Analysis (NHABA) a couple nights ago about aging and the treatment of behavior after trauma. Just as we need to assess risks, document needs, and update our FBA and behavior plan processes for a child after trauma, we need to insure our behavior support is trauma-informed for adults when needed. Some of the challenges our gerontology clients with behavioral needs may have been through include war, immigration, natural disasters, or poverty; abuse, mistreatment, or neglect; having behavioral diagnoses caregivers may not have understood when they were children; head trauma accumulation due to sports, car accidents, abuse, and self injurious behavior; and brain changes due to a lifetime of fetal alcohol syndrome, polypharmacy or drug abuse, or seizures. Some of our clients have all of the above and also an intellectual, physical or social disability or difference. Many also have mental illness. And even more of them may be lonely. 

Some of these factors are not necessarily “traumatic” and some individuals may have incredible resources, genetic differences, more social support and other things that can “buffer” against the difficulties of life. But even if someone responds better “emotionally”, studies suggest that “ACES” (adverse childhood experiences) accumulate over time and the load of these can contribute mightily to medical needs throughout someone’s life.

Some of my supervision clients have requested more resources and continuing education or CEU’s on topics like aging and trauma, as well as behavior support in nursing homes, the community, and mental health or medical facilities and prisons. It’s important to address these exact needs seen in so many of our recent clients who struggle to transition to a more appropriate environment (not to mention one that is more ethical given the situation) because of ONLY their behavior; they lived for 5-15 years behind locked doors (and in some cases, under the 24 HOUR scrutiny of security guards!) in nursing homes, hospital wards, and mental hospital facilities. Each was elderly. Each had a previous behavior assessment that didn’t take important needs related to previous trauma into account. Many have now transitioned to seriously less restrictive environments in the community after behavior reduction and skill acquisition, plus collaborative programming by a large team (including mental health therapists, hospital administrators, transition specialists, speech, occupational and physical therapists, medical and psychiatric team members, and a BCBA-D). It’s not that aging, with its complex needs, goes unaddressed– there is a good special issue of Behavior Therapy (2011) if you’d like to read several articles on it — but sometimes it is helpful to offer specific supervision experiences clinicians will use to document and address the risks in this special population, work collaboratively with staff and administrators in long term care settings, and assess and meet needs. Among the challenges my clients face are behavior needs exacerbated by historical experiences we need to take in to account when working with their trauma informed transition teams.

So, in this context, let’s briefly return to “TIBA” and some questions that the term raises.

Clinical folks, do we need it? Is it useful to single out a population for CEU’s, training, courses, or experience?

Well, do we need to know if a person has “autism” or “early intervention” or “feeding” or “gerontology” experience if we are posting a position in that area?

Not everyone agrees that it’s needed to call behavior analysis something different when it applies to trauma. (I agree, and have written here about how TIBA, as a term, is redundant—and why I use it anyway).

In fact, maybe “Geriatric Behavior Analysis” is redundant too. Age is just a number, right? Behavior is behavior, right? Or… do we apply behavior analysis a little differently, not with more care but with care, with a different KIND of care, knowledge, skill, if our client is 83 years old, fragile, going through depression and suffering from traumatic brain injury and mental illness related to previous sexual or physical assault? How about the problems their staff face… is it a little different teaching teachers who are energetic and excited to shape young minds, and teaching staff who lose a patient to illness or death every couple of weeks? Their jobs are not always valued, and their work environment is very challenging in physical and emotional ways beyond simply implementing a behavior plan.

Of course, for each special population and the complement of caregivers it attracts and maintains, there is a special and important set of challenges, solutions, and applications. Many are similar, and most are DEFINITELY applicable to the others once learned.

Yet, their histories are different. Their risks and needs are different, and the training to enter the subfields is a little different…. But just a little. Experience with the population matters, of course. Specialized CEU’s and supervision topics are helpful to their practitioners. Still, the principles of behavior analysis are all still applicable. Nothing about TIBA erodes behavior analysis, or renders its principles ineffective. But we are tasked in our Ethics Code to practice within our boundaries of competence (see item 1.02), even as we expand them (and see LeBlanc, Heinicke and Baker 2012 on expanding our consumer base).

Bottom line: Students, ask your supervisor how they can help develop your skillset in this area. In my own supervisee teams we use adult oriented assessments to document special needs related to traumatic histories. We document related setting events and conditioned stimuli in the environment related to challenging behavior, stimulus control problems, and skill gaps. We use this information to build skills for young behavior analysts interested in learning to collaborate with large groups of staff and administrators as they team to meet the complex mental health, social, physical, and behavioral needs of people whose trauma backgrounds make aging related challenges more difficult. As our population ages, and if you’d like to do this work, it’s meaningful; it can be exciting. (Exciting? YES! How about watching the principles of verbal behavior in action as an elder with dementia gains back some language to use, improving the quality of their last few years of life!)

And it grows ever more urgent.

Send us a note at Cusp Emergence or Cusp Emergence University if you’d like to submit a topic idea for CEU’s or a webinar for your team!

Farewell to Dr. Janet Ellis

This topic can’t be addressed without thinking of a dear woman we lost this week, Dr. Janet Ellis. A powerhouse at University of North Texas, Dr. Ellis helped start one of the country’s first Behavior Analysis Departments, published some of the earliest reports of functional analysis in schools, and taught probably thousands of students in her 30-year career at UNT. She ran a lab doing FA’s in schools, and taught classes with passion and candor. She was generous with her encouragement of all students in the department, gave great feedback, and shared her knowledge of the literature. I loved watching her stick her hand into one of many high stacks of articles clustered on her desk to pull out exactly the right reference for a specific question.

Realizing many of my mentors are now in the population that requires caregiving, I think of how people begin (and most end) here, needing care. In between those points, we live full lives providing caregiving, and other acts of service, to others. If we allow it, behavior analysis provides ways for us to be more consistent and compassionate in that role. This field helps me to understand behavior to empower those who empower others- the teachers, staff, caregivers and life changers in our schools, hospitals, service agencies, homes and communities. We have a short window to give as much back as we can, between the times we must be taken care of. 

Companion Notes and Questions for Students or Supervisees:

1. Look up an article related to behavioral gerontology if you have heard about it through this article. You could start with the one referenced by Baker et al. 2006 (link in references), check out behavior analytic research on dementia, or read about verbal behavior approaches to this issue.

2. State the definition of each dimension of ABA and describe how it can apply to an intervention. I’ve started you off with an example in this post using Baker’s article. If you need to, consult Baer, Wolf and Risley (1968) for assistance with definitions. (But also see Critchfield and Reed (2017) for an interesting counterpoint, The Fuzzy Concept of Applied Behavior Analysis Research, to discuss with your supervisor or in a group supervision! Personally I think the over-application of the 7 dimensions is a rule-governance problem I’d be happy to discuss in a group supervision online any time.

3. If you are interested in this area, look up a program that offers coursework, CEU’s, or a certificate or contact local programs who provide behavior analysis with adults and learn about job opportunities for part of your supervision hours. (Several programs specialize or include courses in gerontology or geriatric behavioral health. A growing number of behavior analysts (including researchers) are applying behavior analysis with aging populations or in nursing homes. But a very large percentage of the aging live at home in their own communities, and private companies who have been devoted to autism are expanding to serve adults. In Colorado you may find opportunities at Community Center Boards; you can also look up behavioral hospitals, residential treatment facilities, behavioral health providers, regional centers and nursing homes.

4. Look up the behavior analysis associations mentioned in this post. If you have not already, look up your own local organization and write down what it would take for you to get to their conference (or if you’ve been, submit a poster) next year.

5. Have you ever joined a SIG (special interest group) at ABAI (Association for Behavior Analysis International)? Check out Behavioral Gerontology Special Interest Group with ABAI: https://bgsig.wordpress.com/

References and Links

Baer, Wolf, and Risley (1968). Some Current Dimensions of Applied Behavior Analysis. Journal of Applied Behavior Analysis, 1 (1), 91-97.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1310980/

Baker, Hanley and Mathews (2006). Staff-Administered Functional Analysis and Treatment of Aggression by an Elder with Dementia. Journal of Applied Behavior Analysis, 39 (4), 469-474.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1702326/

Critchfield and Reed (2017). The Fuzzy Concept of Applied Behavior Analysis Research. The Behavior Analyst, 40 (1), 123-159.

https://link.springer.com/article/10.1007/s40614-017-0093-x

Behavior Analyst Certification Board. (2014). Professional and ethical compliance code for behavior analysts. Littleton, CO: Author.

https://www.bacb.com/wp-content/uploads/BACB-Compliance-Code-english_190318.pdf