Category Archives: behavior cusp

Too risky to document risks?

17 Tuesday Jul 2018

Posted by in adults, Behavior Analysis, behavior cusp, Behavioral Cusp, boundaries of competence, collaboration, Community, Education, ethics, resources, risk analysis, risk assessment, risk versus benefit analysis, supervision, teaching behavior analysis, teaching ethics, trauma, trauma-informed behavior analysis, Uncategorized

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This post is part of a series on trauma-informed behavior analysis by Dr. Camille Kolu, Ph.D., BCBA-D.

When treating behavior concerns after trauma, we may find that clients exhibit risks to themselves, risks to their community, and risks to caregivers that should be documented. Why have behavior analysts sometimes turned a blind eye to documenting these risks? Read on to discover some common reasons I found in the field, and ways we can address them. 

When it’s too risky to even consider the risks

Our field has adopted a Compliance Code which mentions the need to document risks. As an instructor for courses in a BACB-approved course behavior analysis course sequence, I use a textbook that provides sample templates for documenting and analyzing risks. And as a practitioner, I have found that my analysis or assessment of risk is almost always helpful to a case (as in some situations I’ll describe below), not to mention that it’s quick and simple it is to do.

Despite these facts, most behavior analysts I encounter do not analyze risks in any sort of written format. The behavior analysts around me range from BCBA-Ds to RBTs, and many have expertise and long careers. Why are we averse to documenting risks?

I have been researching the answer to this question for several years, and often the answer is “because I don’t have a good risk assessment”. So I made some and piloted them with different agencies, working through the problems of how to identify, define, document and mitigate the risks related to the populations with whom I work most closely. But at a recent training opportunity I received a different kind of answer, and I think it’s too important to keep to myself.

Some of the BCBA’s I talked to at that event were not documenting risks, they acknowledged, because it was just too risky.

At first it seemed counterintuitive. If I was providing a new document that made it easy to document several options, and the potential risks and benefits of each, wasn’t that inherently reducing the risk? No, it turns out. To many of us, highlighting a risk necessarily imposes some degree of liability.

We’ve faced this challenge before. In pointing out a problem we may become partially responsible for solving it, as some educators have learned the hard way when their schools are upset with them for discussing the observations of a student’s difficulties outside of the official process. This responsibility may carry a financial burden or create an unsolvable problem in a resource-poor area. And some pediatricians I know have mentioned the frustrating dilemma of being given a new depression screen for teens or moms, only to have nowhere to go with the results.

A new ethical responsibility is only as useful as your agency’s process to fulfill that responsibility, and procedures to support the people implementing the new responsibilities.

And in the discussion with the BCBA’s that day about risk documentation, I learned something really interesting. The specific language I used made a huge difference in their willingness of adopting a new procedure.

When I called it a “risk assessment”, BCBA’s were unwilling to adopt my new “assessment”, even if it was backed up by the compliance code and plenty of evidence and anecdotes how it has supported my work.

But when I called it a “risk versus benefit analysis”, they were willing to try.

The difference?

“Risk assessment” is a loaded term that carries legal weight in many contexts.

On the contrary, the other term (“risk versus benefit analysis”) is something that I use daily, and that is simply a process of documenting and analyzing the several different options available, together with their respective potential risks and benefits. It’s called for by the Compliance Code (and discussed by Bailey and Burch in their Ethics text).

According to the Compliance Code, “a risk-benefit analysis is a deliberate evaluation of the potential risks (e.g., limitations, side effects, costs) and benefits (e.g., treatment outcomes, efficiency, savings) associated with a given intervention. A risk-benefit analysis should conclude with a course of action associated with greater benefits than risks.”

The Compliance Code mentions risks in several places. In 2.04b, we are to consider risks of performing conflicting roles (e.g., when we are clarifying third party involvement in services). In 2.09c we are asked to use a risk-benefit analysis as part of our process in deciding between different treatments. And in 4.05, we are asked to work with stakeholders to present the potential risks versus benefits of which procedures we plan to use to implement program objectives. 7.02 asks us to consider risks involved, when there may have been an ethical or legal violation by a peer. And of course, we consider the potential risks and benefits when doing research (9.02).

The Task List does not mention “risk” by name, but alludes to the process when requiring that we are required to be able to state and plan for the possible unwanted effects of reinforcement (C-01), punishment (C-02), or extinction (C-03), as well as behavioral contrast (E-07). Similarly, the Code makes it clear that we are to identify potential for harm with using reinforcement (4.10) and identify obstacles to implementing recommended treatment (4.07).

In my practice, the most efficient way to meet all these objectives and more, is to complete a risk-benefit analysis. I love to include sections on mitigating the risks I do identify, so that the team can make an informed decision about what resources, training, information or support they will need to implement the least risky option.

And a final benefit I’ve heard many stakeholders mention during this process (and typically I do the analysis as an open discussion in which they are involved and brainstorming), is usually stated like this: “I didn’t think we had any other options, but when we approached this with a goal to identify alternatives and the risks and benefits of each, we uncovered several more”.

The risk versus benefit analysis is something I document, add to a treatment plan or employee or client file or IEP, or simply something I share with the team in writing and in person to solidify systems support for my next move. Recently, the following situations were ameliorated by using a transparent risk versus benefit analysis. Outcomes included increasing appropriate funding; securing appropriate medications; identifying appropriate caregivers; funding appropriate training; and improving client satisfaction.

-what kind of residential facility would be most appropriate to move a client to

-whether to discharge a client now or later

-whether to use a cheaper program with fewer resources or a costly one with many

-whether to put a client in a foster home in a potentially risky but supportive situation

-whether to delay an assessment to have an operation

-under what conditions should we discontinue a client who violates our informal no-show policy

-what caregiver to select from several available

-how to appropriately include police contact in a plan in a way that reduced long term risks

-what medication to decrease and when

-whether to put a student in a restrictive school with more behavior support, or a less restrictive placement with more social interaction options

As you can see by the last two, sometimes these decisions are not cut and dry. They depend on the team and family input, and one family may weigh a given outcome more heavily than another.  Everyone has a history. To do these analyses in a compassionate and open way is important, and sometimes we don’t agree. To involve high level stakeholders and funders is critical as well.

What are the risks of doing a risk-benefit analysis? Perhaps you’ll highlight more risks than you thought were there; perhaps you’ll have to take some responsibility for the outcome of your recommendations. But what are the risks of avoiding this important process? If you are certified, your responsibility as a behavior analyst “is to all parties affected by behavior-analytic services” (e.g., 2.02). So are there risks of not documenting risks? Sure. You could cause harm or be negligent if there is a known risk you didn’t plan for or discuss with the team. Just like there are risks, there are benefits too. Doing a good risk versus benefit analysis is certainly a helpful cusp for supervisors and behavior analysis leaders to acquire! Many times we have uncovered risks that can be totally avoided next time if we were to act now to change or solidify policies, or use preventative measures in the future. A risk-benefit analysis can be a wonderful contribution to discussing lessons learned.

There are more options to be uncovered. Go out there and find and document them!

Want a resource? Check out the 3rd edition of the Bailey and Burch text Ethics for Behavior Analysts (2016), read more on Cusp Emergence , or check out a risk versus benefit tool (I like to do this on a whiteboard with my teams).

Convinced? Have a question? Drop us an email. And thanks for reading about this important topic. We’d love to see how YOU document and discuss risks!

Beyond My Current Competence

20 Tuesday Mar 2018

Posted by in adults, Autism, Behavior Analysis, behavior cusp, Behavioral Cusp, boundaries of competence, children, collaboration, ethics, resources, risk assessment, supervision, teaching behavior analysis, teaching ethics, Uncategorized

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Whether you’ve been in the field for a year or twenty, and whether you feel like you make a difference each day, or struggle to go to work, anyone can benefit from deliberately expanding their boundary of competence. Perhaps you’ve had calls from a potential client and had to turn down the opportunity, lacking the experience, training, supervision, funds, or continuing education to say yes, or to provide treatment for that particular diagnosis, age group, type of agency or setting, or behavior. If you can identify, you are not alone. In my recent poll of a group of behavior analysis students in a post-master’s degree course that counted toward the BACB requirements for sitting for the exam, 100% of students identified that they were currently working in the autism field. Despite their lack of exposure to other fields, there was certainly no lack of interest! 40% of students were interested in getting involved in education; 88% of students wanted to know more about behavior analysis in animal welfare; and 63% wanted to learn more about behavior analysis in child welfare and human services, including intellectual disabilities. Seventy-five percent of students would have liked to expand into behavioral gerontology, 69% into behavior-based safety, and 56% into organizational behavior management. And a full 100% indicated they were interested in learning how they could use behavior analysis to support those with brain injury!

With this diversity in the interests of entry level certificants (and an array of actual jobs that is even more rich), it is always amusing and a little surprising to see this frequent question on social media: “is there anyone here who practices outside of autism (or its cousin early intervention)? If so, how could I grow my practice?”

Fortunately, the same foundational knowledge, skills and tools that helped you to grow your clients’ repertoire apply to this opportunity that you face. Maybe you’re thinking this is easier said than done. But stick with me… maybe that’s just the initial impression you’re getting from the seeming lack of exemplars. Let’s talk about a skill that’s already in your repertoire: arranging a supportive environment for doing something new.

First, it might help to connect with your “values”, goals, or reinforcers (see this article on values in behavior analysis using the ACT (Acceptance and Commitment Therapy) framework). Or you might find it helpful to jot down your answers to questions like this: What do you want to be doing in 5 years? What is one thing that if you began to do it, your entire life would change? Who do you most want to help in your lifetime? What gets you so jazzed up you can’t stop talking about it? Israel Goldiamond, the father of the Constructional Approach, asked similar questions in his Constructional Questionnaire. I think of this as the best motivational interview out there, and you can find it around the end of his wonderful 1974 article, reprinted in 2002 here (see page 187). He wanted to know, “assuming we were successful, what would the outcome be for you?” Another way of asking this question is to ask yourself what “cusp” you need most to achieve your goals. (See this article on how identifying a behavioral cusp can help you make leaps of progress.)

Now that you have gotten in touch with your “why”, you need to arrange some ways to contact related reinforcers, and to see exemplars in action. Just as a video model helps my 13 year old client learn to make a sandwich and see the results – consuming the delicious hand made treat—I was inspired and more, when I broke out of my comfort zone and attended conference talks that only remotely applied to my then-current work in autism. I watched OBM talks, animal talks, behavior safety and gerontology talks, and went to every talk on behavior analysis in mental health that I could find. RELATED TIP:  At conferences, approach speakers who inspire you from different and related fields. Ask them for suggestions. Select a recommendation, apply it for several weeks, and contact the person to follow up and thank them.

When first branching out (or planning your leap), I recommend that you spend some time dedicated to being a generalist. Nearly every area has at least some agencies that support people with developmental disabilities or differently abled people of all ages. Around Colorado, I can do this by connecting with Community Center Boards, ARC’s, and county organizations. If you don’t find full time opportunities for paid work with these organizations, you can gain the same benefit through volunteering at an agency similar to those I have named. The great benefit of this suggestion is that you rapidly move beyond being “a person with experience with autism and early intervention”, to someone who has been around inclusive support of people with an array of developmental, intellectual, and genetic challenges. Doing this step before working on my own meant that I was now experienced with all ages and settings where people might experience treatment, ranging from private residences, host homes, group homes and mental hospitals, to all kinds of day programs.

Next, I encourage others in the “before you leap” stage to begin to collaborate intensively and intentionally. You can do this wherever you are, of course. I can’t count how many letters I have written to the client’s pediatrician, physician, dentist, feeding therapist, psychotherapist, occupational and speech therapist, advocate, social worker, police department, psychiatrist, psychologist, adoptive caseworker, and nurses. When and why do I do this? I initiate the contact to surrounding professionals (when appropriate and after obtaining written permission from the guardian, of course (see Compliance Code Guideline 2.03 and 3) at the onset of a case when I am conducting my documentation review, as part of the FBA (Functional Behavior Assessment). I do this to let the potential collaborator know I am doing an assessment in case it impacts or informs their own clinical work, and request documentation if needed for my assessment. I don’t always hear back. But when I do, these connections grow my network and enhance the client’s collaborative care. And the professional may write months or years later and ask for collaboration or consultation or training for their staff!

At the end of services, a report may not be required. But write it anyway. It helps to document the closing or transfer of a case in an appropriate way, and provides a way for you to leave your information for all parties in case someone wants you to collaborate in the future. Be sure to add the 3 R’s: Always embed resources, risk assessments, and referrals in your reports. The risk assessment piece has helped me grow my career in several ways. First, it’s just plain good (and ethical) practice to document the risks and potential benefits of current and other possible options for what your client is considering. But it’s also a little new to the field; it’s not quite standard practice although it’s a standard recommendation. I have had referrals to do educational evaluations and consultation for companies and agencies who happened to see one of my risk assessments embedded in a report.

RELATED TIP: Graph other people’s interventions. You already know you’re responsible for helping understand the effects of related interventions if the client is receiving more than ABA. But this is also hugely educational for the other professional, and fosters future relationships. What psychiatrist wouldn’t appreciate a cumulative record of challenging behavior or new words learned, with lines on the graph showing her when the medication changes occurred? What social worker would turn down a graph of her home visits and the child’s family interaction, superimposed on a graph of the client’s challenging behavior? What school teacher wouldn’t appreciate a graph of new skills learned at home at the same time as school interventions were occurring?

The above tip only works as long as we respect others and value others’ work. Try to learn about it before you offer to help or intervene, never ask a team to take data before looking at (and perhaps graphing) what data they are already collecting. And I like to enter any environment with a “tips sheet” that puts into words some basic strategies that will help promote appropriate behavior, leaving them with my contact information and availability to collaborate if they need support or want to learn more about behavior analysis. (See this earlier post on collaborating within hospital environments for similar ideas).

Tips for entering a provider network that you’re not familiar with: You can contact a caseworker for the agency and ask to speak with someone in their administration. Or you can ask how people become providers. Usually there is an upcoming provider fair in the next few months you can get invited to. Finally, ask if they have support groups for families or clients; ask if you can audit a support group to learn more about their needs. Be quiet and respectful during this time that families are sharing, and think about ways you would be able to support them. Don’t ambulance chase; follow the ethics code and find other routes. (While you wait you can apply to be a provider, and offer to do a free basic training on behavior analysis and how clients can benefit). The agency may start connecting you to families at that point.

Give back and stay connected. I practice these tips regularly: find a mentor, meeting with someone regularly who can guide you. At the same time, I meet regularly with people who likely can’t help me, but to whom I can be a good source of advice or support. At any level you can do this; BCaBA’s can help to mentor an RBT; BCBA’s can mentor BCaBA’s and RBT’s; and BCBA-D’s can mentor each other, and BCBA’s. Sometimes finding a complementary professional who is in a field that’s only slightly related can be a great source of networking and support, as I find with professional friends who are not behavior analysts but who are mental health therapists, psychiatrists, and psychologists.

Some final thoughts: Ask for supervision and mentorship actively. (We live in an age where you can easily have phone or internet meetings with someone across the globe whose experience you lack.) Give referrals to others (help others grow their networks). Read articles, and attend conference meetings, slightly out of your field. Check out what other behavior analysis professionals have to say about expanding boundaries. Contact conference presenters. Trust me, we usually welcome it. Be interested in other people and their work, research, articles, podcasts, what they love to talk about. DO give a firm “no” before, not when, you are overloaded (this helps you do a good job in every case). When you have to say no, teach people how to locate a behavior analyst in their area. Keep growing your skillset (my current frontier is an ACT supervision group I have joined with therapists who are not behavior analysts). And finally, try keeping a yes/no log! This is a place to write down the contact information, date and nature of any referrals or opportunities you received, that you must turn down because you still lack the mentorship, experience, continuing education, training or supervision. Check whether the opportunity aligns with your values and goals (see the first step we discussed today). If it does, then program for yourself an action plan in which you identify at least three actions that put you closer to saying “yes” to similar opportunities in one year. One year later, check in with the old referral and let them know you appreciate the ways they helped you grow and that you’d be happy to meet for tea to hear how they are doing.

If this post helped you, let me know how YOU are doing… or feel free to write me and add suggestions and solutions you have found. May we all keep growing! 

Resources

LeBlanc et al. (2012) on expanding the consumer base for behavior analytic services

https://www.researchgate.net/publication/234159161_Expanding_the_Consumer_Base_for_Behavior-Analytic_Services_Meeting_the_Needs_of_Consumers_in_the_21st_Century

Website on Goldiamond’s Constructional Approach: https://behavioranalysishistory.pbworks.com/f/The%20Constructional%20Approach.pdf

Goldiamond’s article Toward a Constructional Approach to Social Problems (you can download the PDF by first going to this page):

http://journals.uic.edu/ojs/index.php/bsi/article/view/92

Article on “values” in behavior analysis using the ACT framework:

Click to access bhan-32-01-85.pdf

Article on ACT and behavioral activation related to depression and avoidance:

Click to access bhan-29-02-161.pdf

Part 12 in Trauma-Informed Behavior Analysis: What’s behavioral about treating reactive attachment disorder?

26 Monday Feb 2018

Posted by in adults, Behavior Analysis, behavior cusp, Behavioral Cusp, children, collaboration, Community, Education, ethics, RAD, reactive attachment disorder, risk assessment, supervision, trauma, trauma-informed behavior analysis, Uncategorized

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(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. Continue reading →

Part 11 in Trauma-Informed Behavior Analysis: Very early learning relates to behavior much later (see end of post for several references)

02 Monday Oct 2017

Posted by in acquisition, adults, Behavior Analysis, behavior cusp, Behavioral Cusp, children, Education, ethics, extinction, learning, teaching behavior analysis, teaching ethics, trauma, Uncategorized, variability

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Trigger warning: This topic is disturbing and sensitive, yet I wish more behavior analysts applied their science to this ugly real world problem.  Let’s face the hard thing together, by discussing some effects of initial learning on later behavior and learning. Several references are below for this topic: How acquisition predicts extinction; variability during acquisition and extinction. This article is Part 11 in a series on how behavior analysts can grow towards supporting children and adults affected by trauma, by Dr. Camille Kolu, Ph.D., BCBA-D.

Severely aversive experiences affect us for a long time. And acquisition can predict what someone’s behavior will look like during extinction (or how behavior will depend on original learning even long after those variables are “gone”). A BCBA recently asked me for references on this topic during SAFET logo letters onlya training I provided to an autism agency on how to provide safer and more appropriate supports for individuals affected by events we characterize as “traumatic”. Thank you to the BCBA for the excellent question!

At first try, we might have a hard time finding references and resources showing how a young child’s traumatic history leads to bizarre and challenging behavior much later in life. If this seems strange, consider how absurd it would be to suggest that caregivers are carefully documenting and reporting how they deprived a child of the food, comfort, diaper changes and other kinds of care the child needed as an infant or growing young person. These tragic events are usually documented after, not while, they occur (if ever). But at least scientists can get familiar with how early learning affects later learning, and behavior later in life. This helps us to make sense of otherwise bizarre behaviors, provide important contextual information to caregivers and decision makers, and even to inform our preventative treatment of behaviors that don’t seem related to the ongoing situation.

Behavior analysts or psychologists might relate this to how early learning conditions affect subsequent learning, or how the variables present during early learning exerts effects on behavior, after that situation is no longer present. This discussion is to provide some examples of literature that might be useful for behavior analysts interesting in exploring this topic.

In my work with children and adults after traumatic experiences before and during foster care (or other traumatic events including long duration life threatening illnesses or aversive experiences), I have been collecting data on the types of behaviors that “show up in the behavior stream and repertoire” of children who were exposed earlier – and in some cases much earlier- to situations of neglect and abuse. Continue reading →

Part 10 in Trauma-Informed Behavior Analysis: A behavior analyst walks into a hospital

29 Friday Sep 2017

Posted by in adults, Behavior Analysis, behavior cusp, Behavioral Cusp, collaboration, Community, data, hospital, trauma, Uncategorized

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This article is Part 10 in an ongoing series about ways that behavior analysts can practice in a “trauma-informed” way. Considering that behavior analysts need to be ready to participate with medical and other providers, this article shares some lessons learned about becoming involved with the medical team. Whether your client is going through trauma or not, it should be helpful. But it’s particularly important for my clients who are being treated in intensive settings for their mental and medical health (often resulting from years of trauma). Be well, Dr. Camille Kolu Ph.D., BCBA-D

One of the ways I like to learn from others is hearing their “lessons learned”. By listening to them share what they have learned and what did or didn’t work, I can hone my own role and be more prepared the next time I enter a similar setting. For many of us, the mental or medical hospital is a new frontier. What can we behavior analysts can do to help in this type of setting?

I think about my role this way: As a behavior analyst, I am not the person’s medical doctor. But we often need to collaborate- and yet most medical professionals are not extremely familiar with collaborating with us. What can I do to support our mutual clients, making their healers’ work more effective?

Here are some ideas that have helped me to integrate into these settings more effectively. In some cases they are lessons I learned when I failed to do something up front that could have made a marked difference later on. In all cases, we have an ethical imperative as behavior analysts to get a medical perspective (or to rule out medical concerns) when there might be a medical component to behaviors that are challenging… but most home and clinic based behavior analysts don’t typically work in the hospital settings.

Continue reading →

Part 8 in Trauma-Informed Behavior Analysis: When a label masks needs

12 Tuesday Sep 2017

Posted by in Behavior Analysis, behavior cusp, Behavioral Cusp, children, Community, Education, trauma, Uncategorized

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Buzzing underneath: Wisteria, the bees, and the fly

When you look at this picture, what do you see? wisteria.jpg

When I look into this painting I see pieces of my family’s home.

I see my mother and how she loves wisteria; how she tends it so carefully; how she protects it every year from the freeze. In Texas the freezes may come far between and at strange times. If we can we protect what we love.

When I see this painting I also see through my father’s eye, for he took the photograph on which my painting is based. I look through his eyes and notice how he sees a story in everything.

Some people see other things.

To some it looks beautiful and calm on the surface. Soon, this tree will be getting ready for its annual sleep, when it will look – for months—like a dead thing. But at a certain time of spring, its glory may return (if my mother saves it). And it will become alive with something you don’t see:

At a certain time of year, if you wandered nearby and stared closely, then underneath and within and all around the blossoms that seem like you could just touch them, this tree would again be swarming with bees.

So there are those of us who wouldn’t be able to lean in, to breathe deeply of its fragrance.

There are those of us with life threatening allergies to bees!

And some of us derive our fear not from specific allergies – and to us the stimulus is not exactly the same as poisoning us – but is still just as scary. Perhaps this can be overcome. Perhaps I can use my behavioral skills to get you closer and closer to a bee. Perhaps you’ll hold one in your hand, someday.

But for a moment I just appreciate the reasons some people are scared to approach what others find beautiful, and can love without abandon.

Some troubles are only seen underneath layers of other showy blossoms.

Some are not seen at all.

I think “showy” is such a descriptive word. During certain childhood years of mine, mom studied botany and carefully “keyed out” plants on the dining table, painstakingly identifying each tiny part, comparing each to a photo in her book, making her own drawings and descriptions. And this was just fascinating to childhood me.

Truly, it did not reduce my wonder at their beauty—to discover all the names and parts and the inner workings.

If anything, it heightened it.

Today sometimes I think about that when I appreciate the wonderful complexity that is a person.

Sometimes “behavior analysts” are thought to be incapable of appreciating the emergent wonder that is behavior! But naming all the functions, carefully looking at how the environment exquisitely shapes the behavior of a little child growing up, this only increases my fascination with people and the beauty in each person.

Each child’s history includes millions of moments, genetics, their surroundings, and more… all the things that made up their world.

Buzzing underneath: But why?

Something erratic and buzzing intruded on my thoughts this morning, startling me out of my contemplation while driving to see my client.

No longer focused on the road (and the flowers I’m painting this week), I looked around frantically to isolate the buzzing sound.

It was just a fly.

But for a few moments I was pretty distracted!

I was undaunted to get him out, whatever I did. It took a little while. I noticed a slight elevation in my heart rate, a lapse in my concentration.

And it was just a fly.

What if it was a bee and I was allergic? I imagined myself allergic to something, in that closed space with me, and me, driving, unable to get myself away.

Recently I watched a boy in a 2nd grade class who had been labeled with “ADHD”.

He moves a lot.

He can’t sit still.

He’s pretty “oppositional” and “defiant” too.

He gets distracted. He argues. He picks fights. And he never ever brings completed homework to school.

But I know a secret.

He moves a lot… between family members.

Some of them yell and hit each other.

Sometimes they sleep in their car.

Sometimes it gets impounded. I don’t know where they sleep then.

Sometimes they don’t eat much at night.

And like the flowers I love, which is my luxury to do because of my happy childhood, many of his “behaviors” are showy.

And you know what? They mask what’s underneath.

This series of trauma-informed behavior support continues with a few more “masks” in upcoming articles – such as when physical aggression masks a medical challenge, or verbal aggression masks brain injury. We’ll talk more about what we can do, and discuss the important ideas behind “differential diagnosis” and differentiating local function from historical function.

The past few years have seen an increase in child psychiatrists and pediatricians who discuss the possibility of mistaking the symptoms of serious childhood adversity for ADHD. Do we teach to sit still and medicate? Do we provide more recess? Or do we look deeper and see how we can help families, educators and teams?

A related “cusp” for educators and behavior analysts might be conducting an appropriately rigorous or well rounded functional behavior assessment before jumping into treatment. Even if we must be brief, we can ask important questions and include important people. This could make possible many next steps that would not have otherwise occurred.

See you soon, friends.

 

 

 

Trauma-Informed Behavior Analysis, Part 3: Is It Ethical For Behavior Analysts to Treat “Trauma”?

05 Saturday Aug 2017

Posted by in adults, Behavior Analysis, behavior cusp, Behavioral Cusp, Community, Education, ethics, risk assessment, supervision, teaching behavior analysis, teaching ethics, trauma, Uncategorized

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This is Part 3 in a series of how behavior analysts approach “trauma”, by Teresa Camille Kolu, Ph.D., BCBA-D.

Is It Ethical For Behavior Analysts to Treat “Trauma”?

Meaningful answers often depend on asking an appropriate question.

Since this “yes-or-no” question is not the least bit appropriate for many of us to answer “yes” to without more information, let’s start by refining our question.

Under what conditions would it be appropriate for a behavior analyst to treat someone whose behaviors relate to their adverse childhood experiences?

The question above is one way of asking the question, and your team might think of others. It also may help to check out Tuesday’s upcoming article on Behavioral Terminology Related to “Trauma”.

I’ve certainly seen some inappropriate, well-meaning, and harmful treatment of behavior when the children and people involved have been through adverse childhood (or other) experiences.

Part of my concern is that young behavior analysts may have come from a program that did not cover adequately the experimental basis of our field, including schedule effects or concepts like the molecular or molar view of behavior.

I think young behavior analysts who are smart and curious can get these things; they need to have better exposure in their classes (and online course sequences toward certification paths aren’t likely to bring this exposure) or groups (so ask your friendly local or skype article CEU club if you’d like to read an article like this one on the paradigm shift from the molecular to molar view in behavior analysis). This is why a supportive verbal community of reinforcement is so critical for developing behavior analysts (more on that later elsewhere on this site).

(Not sure how to look up pdf’s of articles? An easy way is to first look at the online journal list (for example, for JABA or JEAB) and first enter your search terms, then when you find the article, go to the journal’s archive and click on the issue where the article was published, and download the pdf. This works for all archived JABA and archived JEAB issues through 2012.)

That was fun; let’s get back to the scary stuff: inappropriate, well-meaning, and harmful treatment of behavior.

Sometimes an inexperienced behavior analyst treats only the “local function”, such as treating a behavior in your classroom that seems like it’s related to attention with pure extinction (e.g., without conducting a complete and appropriate functional assessment). This might seem appropriate without more information, but in clients with “trauma backgrounds” or exposure to serious past (or hidden and ongoing) childhood adverse experiences (such as disruptions in primary caregiving and exposure to abuse and neglect), this course of treatment may lead to further harmful escalation, or serious risks and side effects. There are other possibly more appropriate options such as differential reinforcement without extinction, or the preventative schedule approach I mentioned in a previous article. At the least we need to base decisions on better information.

In a classroom where I observed a child who had been through a series of terrible and neglectful situations, when his behavior was placed on attention extinction, he virtually lost all advocacy skills (e.g., stopped manding for help or showing his distress), was being abused by others and never reported it, and started hiding his self-injury which became more and more severe. These were some of the risks involved of using a procedure without evaluating the possible side effects given the child’s repertoire and the reinforcement available for his appropriate skills, and without collaborating with others who had access to the child’s history and current home situation (Compliance Code 2.03b).

The teacher was using the procedure recommended by a behavior analyst, but the BCBA did not know about the child’s history or home life (and did not ask). As I’ve said before, I am NOT asking anyone to stop a function-based approach!- but to demand the information you need to understand the larger context for behavior.

So what’s a behavior analyst to do?

I typically try to think first of ethics (asking, “should I be doing this?”) before diving into strategies (“what should I be doing?”). Here are some ethical considerations:

  1. Is this in my boundary of competence and based on my education, training, and supervised experience?

See Compliance Code 1.02a). If not, it’s a good idea to first seek continuing study, training, supervision and consultation (see Compliance Code 1.02b). I think the skill of reaching out to obtain supervision and mentorship when appropriate (e.g., accepting clients appropriately) may be an important behavior cusp critical to the future repertoires of behavior analysts trying to practice ethically.

  1. I think of ethical behavior analysis as practicing within my boundaries, yet at the same time as growing my boundaries of competence so that next year I will have expanded them and will be able to take a client I said no to this year.

Dr. LeBlanc and colleagues have an article on expanding the consumer base for behavior analytic services that is available for a CEU.

  1. Consider ethics and your own experience and resources carefully, before you begin treating trauma or accepting any kind of trauma-related client.

See 1 and 2 above, and remember not to give advice that stands in for services (e.g., 1.05a). Our responsibility is always to do no harm, and at times the side effects of inappropriate treatment may be riskier than doing nothing (2.09c). It is important to develop a relationship with a mentor who has been there and can assist you to apply new information to an exquisitely sensitive set of problems and clients. If not, arrange for appropriate consultation and referrals (2.03).

  1. All this goes for supervisors too:

Just like we should be careful before we accept a client for treatment, we accept a supervisee who is treating in a sensitive area only after considering our own defined area of competence (5.01). How will we communicate about and report risks (7.02) if we are not experienced enough to recognize and communicate about the risks of our own treatment (2.09)? Agencies may be under particular pressure to accept clients when there is funding, but there are serious risks of doing this too early or without appropriate in-house supervision.

  1. Be prepared for extensive collaboration:

I’ve talked to supervisors who have taken on trauma cases without completing assessments of risks and side effects (2.09c) or collaborating with other therapists the child is concurrently seeing, and this means they are already in danger of not being able to review and appraise effects of other treatments that might impact the goals of the program (2.09d).

Why do you need mentorship, education and experience under supervision first?

This is partly because after you accept a client (e.g., 2.01) whose service needs are consistent with your education and training, experience, resources and policies, your responsibilities are to everyone effected by your behavior analytic services. For example, once I started treating clients affected by trauma, I also found myself treating foster families’ other children to deal with the abuse the affected child talked about, the primary caregiver who used to be on drugs and was trying to demonstrate she could follow a plan and get her children back, and the social workers and other team members who didn’t understand schedule effects and were making placement decisions without data on behavior.

In an upcoming article we discuss some treatment approaches and how we can improve our supervision of BCBA’s treating these serious concerns. But first, next Tuesday covers some behavioral ways of talking about “trauma”. Stay tuned!

And as ever, this information is not a substitute for mentorship or supervision. This is intended for use in supporting behavior analysts to reach out to their own networks and supervisors and mentors, growing their boundaries of competence in an ethical and responsible way.

May we all keep expanding our repertoires.