Category Archives: Education

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!

Part 13 in Trauma-Informed Behavior Analysis: A Pipeline from Special Education to Prison?

16 Monday Apr 2018

Posted by in adults, Behavior Analysis, Community, Education, ethics, functional alternative behavior, RAD, reactive attachment disorder, risk assessment, schedules of punishment, self injurious behavior, stimulus schedules, supervision, teaching behavior analysis, teaching ethics, trauma, trauma-informed behavior analysis, Uncategorized

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(Part 13 of a series of posts about Trauma-informed behavior analysis by Dr. Teresa Camille Kolu, Ph.D., BCBA-D)

Preventing and addressing connections between educational problems, trauma and mental health needs, and the legal system

Perhaps you are familiar with laws making it a crime to assault a medical worker in their line of work. Even the most caring mental health nurse may need to report injuries that occurred helping restrain a confused, drugged, juvenile patient who was suffering from mental health problems, preventing the client from self-harm. Of course, this difficulty isn’t the only way for a special education student to end up with traumatic effects of past interactions that are compounded by legal charges. Why do so many children go from getting kicked out of preschool, through a series of failed educational and residential placements as a teen, to facing jail time before they are fully adults? After hearing Matthew Bennett and friends’ podcast on trauma and criminal thinking, I was inspired to write a behavioral response to share some thoughts for our community.

While behavior analysts and collaborators may be well versed in “schedules of reinforcement”, another type of schedule matters too. This other kind of schedule is in place all around us, is often acting to viciously increase the likelihood of future problems, and may be invisible to most of the educators, foster parents, and even behavior therapists “trying to do the right thing.

We’re talking about schedules of “stimulus delivery” or schedules of interaction. In short, this kind of schedule makes a great deal of difference, whether it is “programmed” (planned in advance) or simply happens— and whether the stimulus is a member of the police, a school or hospital security guard, or the school principal. Even if we are talking about events that are recommended by a response team or safety plan, such as a foster parent coming to pick up a student after behavior is too severe for the school, or physical holds and restraints that take place to keep others safe, all these events can have powerful effects (or side effects) in the behavior stream.

Why do we talk about these events in terms of the “schedule”? In behavior analysis, a “schedule” can refer to the timing of stimulus delivery. For example, suppose a student’s safety plan states that after a certain behavior occurs, a parent will be called. The next few times it happens, the principal will be called in to talk with the student. After that, a safety officer will be called to escort the student off grounds and he will be asked to stay home for 2 days. Suppose this proceeds over the course of about a year, and by the spring semester his challenging behavior has escalated and the last few times, a security guard is not sufficient and the police are called. The “schedule” of delivery might specify that at least one of these things happens every time the behavior occurs… that would be a fixed or continuous schedule. But more commonly, some behaviors are missed, or there is an unfamiliar substitute teacher who doesn’t act immediately and implement the plan, or some similar behaviors occur at home or in someone else’s class but are not treated the same way as the same behavior would at school in the classroom for which the plan was designed.

In fact, research shows that escalating “punishment”, or in other words, using more and more severe consequences over time, can actually increase behavior! This fact, well known to behavior analysts, surprises many educators who thought their prescribed plan would decrease behavior, not escalate it. Specifically, the research shows that if a stimulus is used because the team wants to decrease a behavior (and “decreasing a behavior” is called “punishment” in the literature, even if the team members don’t consider it that way), it is critical that the stimulus is intensive enough for it to be effective (Lerman and Vorndran, 2002), used every time the behavior occurs (Acker and O’Leary 1988), and used consistently and across environments. If used inconsistently, it will likely INCREASE the behavior (Tarbox, Wallace and Tarbox, 2002).

Unfortunately, this common situation has several side effects. For example, the following can all result:

  • Decreased response to the same events in the future and reduced effectiveness of the consequences over time
  • Escalating behavior challenges over time that produce the same or a slightly increased level of punishing stimulation
  • More varied and severe challenging behavior over time
  • Decreased ability of parents or caregivers to control behavior using the techniques at their disposal in the home or residential placement
  • Exposure to more restrictive settings including more and more secure residential facilities
  • Increased tolerance to the event, which results in the system using increased severity to try to keep everyone safe
  • Changing the nature of the once-aversive event (like a police altercation) into something “reinforcing”, or something that the child actually wants or tries to produce
  • Increased likelihood of legal system and police involvement
  • Decreased quality of life well into adulthood and deprivation of learning and social opportunities

As shocking as this may be to families and educators using these systems every day, the results do not surprise a behavior scientist familiar with the literature. Young or inexperienced clinical behavior analysts may not have been exposed to these cold facts, doing harm by not pointing out the risks inherent in many well-meaning school behavior plans or facility safety plans. Did you know a BCBA’s training IS required to include exposure to how to properly implement “parameters and schedules of punishment” (see BACB Fourth Edition Task List, item D-17)?. This means that in cases where punishment, or a consequence based strategy to decrease behavior, is needed (e.g., determined via a risk assessment to be necessary), we must determine ways to avoid escalating behavior (see also section 3.01 and 4.08 in Compliance Code, on the requirements for assessment before reduction procedures, and considerations regarding punishment procedures).

Are you a behavior analyst who hasn’t yet received this kind of important training, or an educator with behavior analysts on your team who haven’t mentioned this? Some suggestions are below for finding a starting place in the literature. Behavior analysts should be familiar with all task list and compliance code requirements for appropriately implementing punishment. Educators might check out this Edutopia piece discussing the use of discipline instead of punishment. A behavior analyst will work hard to avoid punishment. Instead, we begin with a functional behavior assessment that truly illuminates what the child needs and is trying to communicate, in order to build a plan fostering functional communication and coping skills.

Here are some topics to bring up or request supervision on:

  • Relationships between prompts and punishment
  • Using prompts and prompt fading appropriately to reduce, not increase, dependence on caregivers (this topic is strikingly similar to the reasons that least to most prompting for behaviors in acquisition can actually slow down learning the new behavior and increase prompt dependence)
  • Using appropriate parameters and schedules of punishment (calculating effective doses, appropriate timing, and communicating across settings to keep schedules consistent)
  • Risk assessment and analysis applied to behavior plans in environments risking escalating behavior due to inappropriate punishment

Practical skills for teams

  • Ensuring the entire team is trained to use appropriate physical management when needed
  • Training on how to do appropriate physical and crisis management and how to debrief after incidents (minimizing and not strengthening future challenging behavior)
  • Using alternative procedures as opposed to consequence based punishment and attempts to control behavior (instead, behavior analysts conduct a thorough functional behavior assessment and assess risks, focusing on teaching the team how to honor and establish communication attempts and teach coping skills)
  • Using solid communication and collaboration that is preventative and established before the client enters a new environment
  • Communicating in advance with emergency rooms, schools, and police departments in the client’s area

Closing thoughts:

When making placement decisions, the cheapest or first option available may not be appropriate if it contributes to long term risks for the client and community. Many times, a placement decision is made based on promises to get training and keep the client safe as long as nothing goes wrong. In fact, things WILL go wrong (e.g., it should be predicted and planned for). So risk assessments are critical in placement decisions. Teams must be transparent about the short and long term risks of environments that expose clients to models of behavior that is aggressive or destructive. And placement decisions to accept or remove a client due to inappropriate behavior should be evaluated with respect to the function of behavior and long term risks. Is this likely to increase similar behavior, producing long term likelihood of using aggressive attempts to escape environments? Does the team and environment have the ability to support the client to return to the setting after temporary removal due to aggression to others?

When we are thoughtful, collaborative and function-based, we can contribute to slowing the rushing pipeline carrying our clients and family members into more restrictive settings, and exposing them to more severe consequences. Let me know if some of these suggestions educated your team to coordinate behavior support and safety plans that are more appropriate, compassionate and preventative—and please share your own ideas that have worked.

References

Behavior Analysis Certification Board BCBA and BCaBA Task List, Fourth Edition:

https://www.bacb.com/wp-content/uploads/2017/09/160101-BCBA-BCaBA-task-list-fourth-edition-english.pdf

Behavior Analysis Certification Board Compliance Code (2016):

https://www.bacb.com/wp-content/uploads/2017/09/170706-compliance-code-english.pdf

Acker, M. M., & O’Leary, S. G. (1988). Effects of consistent and inconsistent feedback on inappropriate child behavior. Behavior Therapy, 19, 619-624.

Lerman, D. C., & Vorndran, C. M. (2002). On the Status of Knowledge for Using Punishment: Implications for Treating Behavior Disorders. Journal of Applied Behavior Analysis, 35, 431- 464. http://dx.doi.org/10.1901/jaba.2002.35-431

Tarbox, Wallace, and Tarbox (2002). Successful generalized parent training and failed schedule thinning of response blocking for automatically maintained object mouthing. Behavioral Interventions, 17 (3), 169-178.

Lori Desautels (2018). Aiming for Discipline Instead of Punishment, Edutopia, published online March 1, 2018. https://www.edutopia.org/article/aiming-discipline-instead-punishment

Trauma-informed lens podcast: https://connectingparadigms.org/podcast/episode-25-trauma-criminal-thinking/

 

 

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 9 in Trauma-Informed Behavior Analysis: On intervention for fetal alcohol exposure

18 Monday Sep 2017

Posted by in adults, Behavior Analysis, children, Early Intervention, Education, enriched environment, FAS, FASD, Fetal Alcohol Spectrum Disorders, risk assessment, self injurious behavior, Social Interaction, teaching ethics, trauma, Uncategorized

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Early intervention after an unfair start in life: Fetal exposure to alcohol

Those of us who work with people who have lived through adverse childhood experiences are familiar with the importance of individualizing treatment. We can do a lot of harm if we don’t consider what someone went through in life, or if we assume that one child’s preferences and needs are similar to those of another person.

Of course, this series about trauma has emphasized that it is the responsibility of ANY behavior analyst to individualize treatment, to consider the history of a client before moving forward with treatment, and to treat more than the “local” functions of behavior. Unfortunately, it is easy to miss the importance of this component of assessment and treatment, especially for new behavior analysts who have gained their “hours” working with highly similar clients, working without supervisors experienced in a diverse clientele, of without any supervisor or instructor who appreciates experimental as well as applied behavior analysis. One of the ways we find out more, is to go to the literature. This may be easier said than done, and an example of successfully data mining for this topic is provided toward the end of the article.

Today’s discussion involves clients who have been affected by what’s known as “Fetal alcohol syndrome”, or exposure to alcohol in the womb.

This is more than adverse childhood experience, for it goes back further in development, perhaps even as early as the neural tube (which will give rise to the spinal cord) and other important structures were being formed. This kind of exposure can affect an individual for their entire lifetime.

So we can consider it an adverse experience, although it happened even earlier than what we think of as “childhood”, and it has long lasting consequences, altering the way someone will learn and interact for the rest of their life.

Can we treat behavior after this condition? 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.

 

 

 

Part 7 in Trauma-informed behavior analysis: When praise doesn’t work

25 Friday Aug 2017

Posted by in Behavior Analysis, Early Intervention, Education, praise, risk assessment, Social Interaction, supervision, teaching behavior analysis, trauma, Uncategorized

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For readers following our ongoing series on treating behavior affected by previous adverse experiences (e.g., trauma) from a behavior analytic perspective, you may have noticed a few key concepts embedded in the articles and stories I have shared so far. One of these key ideas is this:

After trauma was present in a child’s life, their behavior may seem to respond a bit (or a lot) differently to everyday behavior management strategies.

Because this is such an important idea, I want to say it a few different ways to help you identify with different audiences and members of your collaborative team.

A parent might say, “I don’t know why, but in my 20 years of parenting kids, many who had disabilities and many who were typically developing, I’ve never had a child who just didn’t respond to my regular parenting skills – this child doesn’t respond the same, and not only does my normal parenting seem to not work, but it feels like I’m actually making it worse when I try to help.”

(Empathy red flag: Remember my suggestion to go to parenting or adoption or foster care groups and to listen hard before you try to help? Any behavior analyst knows to first “do no harm”, and it gets real, right here, when we try to help first by “doing only what we normally do” after someone experienced certain kinds of aversive and “traumatic” experiences.)

A special educator getting his behavior analytic certification new to “kids who have been through abuse or neglect” might say, “it’s so weird how the PBS (positive behavior support) and class-wide token system techniques work on my whole class, but they just don’t seem to impact this student at all; I feel like he doesn’t care, and I can’t seem to get through to him”.

A law enforcement professional new to this population might say, “It’s strange how the mother who called us seemed like she was in crisis and the child was about to commit murder, but when we got there the child seemed super calm and talked to us like nothing was wrong; I’m thinking it might be the parent who has mental health issues.”

(Above, this law enforcement example is a red flag for indicators of possible “Reactive attachment” issues that will be discussed in some upcoming articles. It might sound strange to a behavior analyst, but “attachment” is an idea that can be translated and discussed with social workers and caregivers to make sure that the client is receiving appropriate support. Responding oddly to praise is just one  of the indicators of a past challenging history, and telling vastly different stories to different adults can be another.)

A behavior analyst might say, or at least agree, that someone’s behavior responds differently to social stimuli after a series of difficult, life-changing and aversive experiences that occurred with previous caregivers.

And a behavior analyst familiar with using preventative schedules and comprehensive historical assessments to support a client after serious aversive experiences might say, “We need to document what stimuli the person was exposed to in their conditioning history, and how socially delivered stimuli affect their current behavior stream. We need to prioritize the teaching agenda for the caregivers, parents, and teachers, to make sure they know how to deliver preventative schedules [instead of doing the everyday adult training agenda like teaching people to praise appropriate behavior; we know that because of this person’s history, praise may not function as a reinforcer, and may result in worsening behavior over time, if we are not careful about how and when it is delivered].”

It’s important to point out that this article is not about how praise is not a good idea.

In fact, praise is just a social interaction that involves pointing out what was great about someone’s behavior, and it can be as simple as calling out a behavior when a child tries it for the first time (“Hey, you helped out without asking when we cleaned up the room; I bet Ms. Tilly was super happy to get some help. Did you notice how she smiled at you when we left? You’re a part of this school family and we’re so glad you’re here.”)

It’s also not about how to deliver praise effectively or why we praise or how to fade out praise. (If you’re interested in that, check out research on the subject in the Journal of Applied Behavior Analysis or our Why we praise handout).

It’s really about how something—a parenting practice, a behavior management strategy, an educational plan—works, given someone’s history. Often this is in addition to how a behavior functions in the moment.

It’s about individualizing our strategies (which can only occur after appropriate assessment). Praise should be a tool that waters the flowers you want in your garden. If you accidentally dump fertilizer on something you don’t want to grow, what happens? What if praise isn’t like water to a flower, but a weed-killer that will stunt its growth, because of the person’s history, and how it was paired with other stimuli in their repertoire?poppies.jpg

Sometimes we jump in before assessing the history.

Clients exposed to disruption in their early learning histories just don’t respond “typically” to praise.

Praise is not magic.

It’s just another stimulus that occurs in a social context.

By definition, it is delivered by a person, meaning it has a social conditioning history.

For some of us, it was just a signal or pre-condition for bad things about to happen.

Unlike in happy homes, for people who have been through abuse, the history of hearing praise (or hearing adults talk to a child) might not be pleasant, or predictable.

Similar to how the history of caregiving was not necessarily predictable or always pleasant, so we can’t expect that learning to trust a new caregiver, teacher or adoptive parent, or starting to enjoy their praise, or follow their helpful suggestions and instructions, will be easy or predictable.

How can we help?

When we’re lucky, sometimes clients use their words to tell us. My 20y old client who had been through abuse (and was living in a jail setting where she felt “safer” than going home to live with people who had abused her in the past) reminded me, “Dr. K, you already know I don’t respond well to compliments.”

When they’re not able to use words, even if they can sometimes speak, clients use their behavior to tell us that they don’t feel safe, or that praise is uncomfortable or that adults are historically not reliable signals of good things.

Let’s listen.

P.S. Why is “risk assessment” checked as a category or tag for this article? If we don’t assess the risks for using interventions in a case that involves “trauma”, we risk using or recommending a strategy that would work in 90% of your other cases but might increase challenging behavior in this one. If you’re a behavior analyst, you’re already concerned with following our field’s ethics guidelines related to risk assessment.

Part 5 of Trauma-informed behavior analysis: 6 ways to improve your supervision of trauma-related cases

10 Thursday Aug 2017

Posted by in Behavior Analysis, Community, Education, resources, risk assessment, supervision, teaching behavior analysis, teaching ethics, trauma, Uncategorized

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This post is Part 5 in the Trauma-informed Behavior Analysis series by Dr. Teresa Camille Kolu, Ph.D., BCBA-D.

Supervising trauma-related cases? Here are a few tips to help you nurture your team.

  1. Model how to reach out when needed, by reaching out when needed.

Does this seem obvious? Maybe. Do we do it sufficiently? Maybe not. If you want your team to do this with you, show them how you are doing it as well, with your own mentors. Read, obtain consultation, and seek mentorship. I meet rather regularly with a mentor whose experience outweighs mine in some areas (like brain injury) and donate regular time as a mentor for others who need support on issues such as supervision of clients who have been through adverse childhood experiences. It’s easier for me to say to supervisees, “don’t forget to seek ongoing supervision and mentorship when you reach the boundaries of your competence” (e.g., see Professional and Ethical Compliance Code items 1.02-1.03) when they see me doing this at the same time.

  1. Update your team’s FBA practice.

For example, are you documenting the client’s history with respect to aversive experiences, development, and the risks (see Code items 2.09c and 4.05) involved based on their history and behaviors? Are you documenting and fostering robust communication with other professionals involved (see Code items 2.03a-b)? Treating trauma is not the kind of case one does alone (and needs more than a team whose members are all behavior analysts). Cusp Emergence is doing trainings this month for teams who treat cases affected by trauma and we’d love to hear from others on how your FBAs meet the complex needs of this population. The SAFE-T model includes training for supervisors on several components of an ethical and comprehensive trauma-informed behavior assessment.

  1. Understand that clients affected by adverse childhood, medical, feeding or other aversive experiences may differ from your other clients– and that your resulting individualized treatment strategies and recommendations necessarily will differ.

In the next weeks, the “Trauma-informed behavior analysis” series is sharing a couple of articles related to this topic, including “When praise doesn’t work” and “Different types of adverse experiences that change us”. Behavior analysts can document how the trajectories for alternative skill acquisition, or reduction of challenging behaviors, differ depending on their clients’ histories. It can be off-putting to realize that the go-to strategies that worked for most previous clients on your caseload are simply not effective here, but it’s important to know this before you start, because what you don’t know may actually hurt someone! If you think this feels awkward to you as a behavior analyst or teacher, just imagine what this must feel like to a new foster parent of a child with a “reactive attachment” history, when the everyday parenting strategies just make things worse. (For more on this, see #6 in this list.)

  1. Teach your team how to document barriers and risks.

When your staff shares something they overheard a child say, or when your registered behavior technician walks in the house and something fishy is going on, don’t just have her leave with a disturbed feeling… you should already have documented your process for the conditions under which the staff will be required to write it down and discuss it with supervisor and team in a planned way. Over time these documented paths are more important than anyone in the middle of the problem could ever know. For those of us already tasked with reporting MANE (mistreatment, abuse, neglect or exploitation) and honoring our ethics code, it’s important to train staff on what to do with the “not necessarily abuse but definitely inappropriate and risky” situations they see and hear in their line  of work. Don’t leave them to figure out the answers on their own.

  1. Create role maps for key roles on the “trauma triage” team.

This is a tool you can create (an upcoming Resource Wednesday post shares one of ours) that documents the role of each relevant team member. Even if you begin only with the behavior analyst, teacher, and family members on the team, it’s a great start. If the behavior analyst you are supervising is new to trauma, it may be tempting for them to take on too much, to give advice when they should still be collecting data, or to initiate a behavior strategy before you have finished communicating with the social worker about the history of abuse. We can help by using role maps listing roles and responsibilities, making explicit how people can do things within their role that are helpful versus not helpful. Yes, I explicitly spell these out (e.g., if a family is divorced and I work with both sides, I share documents that say how they can help us benefit the child, who remains at the center of the family). “Makes positive statements about mom in front of child” or “writes down concerns with co-parent instead of says them out loud in front of child” are two examples from the recent role map I made for a broken family who was working together for the first time in several years. Grandparents, teachers and anyone who asks “I want to help, but what can do?” also benefit from these role maps. It gives you something to reinforce while you wait, and trust us on this: when there’s nothing specified, people fill in the gaps, often by doing other things that they hope, but that are not necessarily, helpful.

  1. Before you try to help a client affected by trauma, find ways to hear from listen to families who have been there.

There is more on this in an upcoming story, but you can start now by start now researching ways to hear from families in your neighborhood. I learned so much—about what is helpful, and what is simply hurtful and devastating—from volunteering time in various parent support groups, going to county events for adoptive parents, and hearing what foster parents or teachers of children with emotional and behavior disorders are going through. I don’t mean that at that point I was providing any parent support at all, or giving any behavior analytic input: I was just listening to the stories as adoptive or foster parents went round the room sharing from their hearts, their own pasts, and their children’s experiences. The behaviors you hear about will break your heart, and the complex needs of their families may overwhelm you. If you can listen quietly and then you still want to help and not run away, this is a start. Please don’t do this work without this important step. People don’t want to hear from behavior analysts who cannot listen.

I’m listening. Contact me any time.

 

Resource Wednesday: Paradigm Behavior, for family-supportive resources beautifully designed by a friendly BCBA

09 Wednesday Aug 2017

Posted by in Autism, Behavior Analysis, children, Early Intervention, Education, enriched environment, play, resources, Social Interaction, teaching behavior analysis, Uncategorized

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At CuspEmergence, we love finding resources or information we can share with our families and community. Imagine our excitement when we discovered this close-to-home resource, an entire website devoted to helping parents become even more amazing at playing, communicating, and connecting with their children! Paradigm Behavior maintains a website and resource library where families can learn, with the support of a Board Certified Behavior Analyst who is a parent herself. Christina posts blogs, resources for supporting play, and online coaching for families interested in developing play skills, language, and more. Paradigm Behavior maintains a well-stocked Playroom, which could teach students and supervisees cutting their teeth in behavior analysts a thing or about connecting with families and using materials in effective ways.

The resources we found were helpful even to seasoned behavior analysts, taking much of the work out of connecting parents with individualized resources that were at once friendly and helpful. We think you’ll love them as much as we do

Check out ParadigmBehavior.com.

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.