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!
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.
- Recommit to your role as a mandatory reporter for individuals with disabilities, the elderly, or children, if you are a therapist, teacher, etc.
- 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.
- 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.
Call 1-844-CO-4-KIDS if you suspect abuse or neglect
For birth to 3 receiving services: http://coloradoofficeofearlychildhood.force.com/eicolorado/EI_QuickLinks?p=Home&s=EI-CO-Response-to-COVID-19&lang=en
And in Texas, use this info:
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.
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
This is the 17th article in a series on Trauma-Informed Behavior Analysis by Dr. Teresa Camille Kolu, Ph.D., BCBA-D.
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.
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.
Sign up now!
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:
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”: 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.
- We individualize (see BACB Compliance Code item 4.03)
- We should practice within our expertise (1.02)
- 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)
- 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)
- 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)
- Appropriate ABA tackles behavior of meaningful social significance, which it (behavior that is related to historical traumatic or aversive events) certainly is
- Appropriate ABA is conceptually systematic, and treatment of behavior after trauma may be conducted within the conceptual basis of behavior science
- 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)
- 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)
- 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)
- 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.
- For practitioners: widespread practicing out of expertise incurs huge risks to clients, agencies, individuals and communities.
- Many people assume that the application of behavior analytic principles to trauma affected populations requires no nuances, and have harmed others
- 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
- There is not a collective understanding of how the collaboration can work, and many behavior analysts proceed unethically (although unintentionally)
- 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
- will, and do, consider their history of trauma as something that informs everything I will do for them
- will still be practicing behavior analysis, but from this specifically informed perspective
- 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
- including professional educators, school psychologists and therapists who have attempted collaborations that failed because clients’ trauma was overlooked or the practices were ineffective
- 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
- or people who haven’t had ANY experiences with behavior analysis (in my practice this includes people from these groups):
- Lawyers and courts
- Court appointed special advocates
- Social workers
- Trauma therapists
- Foster families and adoption agencies
Dreaming of the future
My goals include that one day in the near future,
- 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.
- 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
- There are multiple funding streams to readily serve the population (examples: foster care, social workers, etc)
- 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, beauty and the bug cusp emergence, ceu bacb, cusp emergence, ethics ceu, trauma, trauma and behavior analysis, trauma and developmental disability, trauma and ID, trauma-informed behavior analysis
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.
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
Articles on prevalence of assault and ACES in individuals with developmental differences:
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
Get the full TIBA (trauma informed behavior analysis series): https://cuspemergence.com/tiba-series/
This post is part of the series on Trauma-Informed Behavior Analysis by Dr. Camille Kolu, Ph.D., BCBA-D.
Sometimes you meet someone who does work that you can really get behind. Over the past month, I have enjoyed learning about Awake Labs, a Canadian company providing easy and elegant solutions to self-advocates, families and teams who need to track information, data, and progress in the context of clients’ stories and strengths. Their Reveal Stories are an interesting way to do this. Awake Labs partners with community educators, providers, and medical professionals, offering ways to collect data and graph progress. During our conversations this month, Paul Fijal of Awake Labs also interviewed me about my work with trauma and behavior analysis, posting our interview on their blog. Check it out!
This post is part of the series on Trauma-Informed Behavior Analysis by Dr. Camille Kolu, Ph.D., BCBA-D.
Why is this in the trauma-informed series? Behavior analysts have ethical responsibilities to disseminate information about our field (Compliance Code item 6.02), cooperate with others (2.03), individualize treatment based on the contextual variables involved in our clients’ cases (4.03), and identify, eliminate and communicate about the environmental constraints on the effectiveness of our treatment plans (4.07). All four of these ethical imperatives can be positively impacted by involving CASA! And these ethical areas are even more important when treating behavior of a person who has been through trauma, abuse or neglect.
Spotlight on team role: CASA, or Court Appointed Special Advocates
Cusp Emergence has had a busy summer! We’ve been continuing public speaking and training, spreading the word about trauma-informed behavior analysis to community partners. There are few things more rewarding than working on a case with a partner who asks us to come back and train their agency, providing continuing education for their team members. This is even more exciting when the provider is newer to behavior analysis. We love disseminating information about the field and hearing from the community!
This post is a shout-out spotlighting CASA. Never heard of them? These people form a compassionate army of people from all walks of life providing long-term relationships and supportive advocacy to local children whose lives involve the family court and foster care system. Some organizational positions are paid to keep the group running, but many are volunteers. The program is nationwide, and depending on the location and jurisdiction, a CASA may be a guardian ad litem or volunteer their time. Some are young professionals, others are retirees; they have in common a passion for children who have experienced inconsistency in caregiving, often including abuse and neglect. Court Appointed Special Advocates receive extensive training and may donate their time to attend visits with the child in the child’s group home, foster home, adoptive family home, residential facility, or hospital. I see them advocating at meetings, attending court dates to speak in the child’s best interest after gathering information; visiting at school; and attending trainings where I provide reviews of behavior assessments and plans. For some children removed due to abuse and neglect, a CASA may be the ONE familiar face present at family court, several foster homes, many schools, and holiday parties held in the hospital where the child was placed after using aggression and receiving a medication change. Caseworkers are familiar too, but may change more than the court appointed special advocates—many of whom follow a child for life.
Maybe you’re a BCBA reading this, thinking “How does this relate to my role?”
First, if you’ve got a client in foster care, you can ask the client’s caseworker if the person has a CASA. If so, you can offer to meet with them and learn more about their role and their history with the person. (I have never had a CASA refuse to meet with me, although this is on their own time—more commonly they are excited to learn about behavior supports, and often advocating to get me on their other cases after they learn more about behavior analysis).
I also train all my client’s CASAs in the functional behavior assessment results and behavior plan. Why?
- On their visits they may see challenging behavior and want to know the best, and most supportive, way to respond or prevent challenges.
- They may conduct unannounced visits in the child’s home or school, and these may be followed by increases in challenging behavior that the team finds confusing. It is helpful to educate the entire team, CASA included, on the changes in behavior that may occur after the child is visited by an unannounced person associated with previous family visits, even if the child typically enjoys visits with the CASA.
- Since the CASA is by definition an advocate, they can be very helpful in sharing information with the court or team that help them to put behavior services in place. In some areas, services can be more difficult to fund if a child has severe behavior needs but not a diagnosis like autism that makes it easy to get insurance on board. In these cases, the county or court may step in and require or help fund some behavioral treatment that is instrumental in helping the foster family understand and manage the child’s behaviors.
Thank you so much, to Becca and Mara at CASA of Adams and Broomfield Counties! It was fantastic to see so many of your team last month.
Want to learn more?
Check out the national CASA movement:
Are you local to the Cusp Emergence community around Adams County, Colorado? Check out the Adams County CASA page (and be sure to attend their free informational event on October 18!)
Read about CASA in the news, with stories about topics like how to become a CASA…
or read from the perspective of a judge whose decisions are informed by their work:
Find the Behavior Analysis Certification Board Compliance Code here:
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.
“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!