Category Archives: Education

Seeing Snakes and Spiders

27 Friday Sep 2019

Posted by in BACB CEU, Behavior Analysis, boundaries of competence, CEU, children, collaboration, Community, continuing education, Cusp Emergence University, CuspEmergenceUniversity, edtiba, EDTIBA10, Education, Education and Trauma-Informed Behavior Analysis, ethics, mental health, resources, sale, teaching behavior analysis, teaching ethics, TIBA, trauma, trauma-informed behavior analysis, Uncategorized

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This is the 17th article in a series on Trauma-Informed Behavior Analysis by Dr. Teresa Camille Kolu, Ph.D., BCBA-D.

spider

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.

rattler

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.

coupon

Sign up now!

Start your fall to-do list: Register now for Paradigm play webinar this Monday (and more)!

06 Friday Sep 2019

Posted by in BACB CEU, Behavior Analysis, CASA, CEU, children, Community, continuing education, Court Appointed Special Advocate, Early Intervention, Education, learning, play, resources, Uncategorized

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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:

https://paradigmbehavior.com/play-registration

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” is redundant. Here’s why I use it anyway.

03 Monday Jun 2019

Posted by in adults, Behavior Analysis, boundaries of competence, children, collaboration, Community, contextual fear conditioning, Education, ethics, extinction, renewal effect, TIBA, trauma, trauma-informed behavior analysis, Uncategorized

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“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.

  1. We individualize (see BACB Compliance Code item 4.03)
  2. We should practice within our expertise (1.02)
    1. 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)
  3. 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)
  4. 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)

  1. Appropriate ABA tackles behavior of meaningful social significance, which it (behavior that is related to historical traumatic or aversive events) certainly is
  2. Appropriate ABA is conceptually systematic, and treatment of behavior after trauma may be conducted within the conceptual basis of behavior science
  3. 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)

  1. 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)
  2. 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)
  3. 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.

  1. For practitioners: widespread practicing out of expertise incurs huge risks to clients, agencies, individuals and communities.
    1. Many people assume that the application of behavior analytic principles to trauma affected populations requires no nuances, and have harmed others
    2. 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
    3. There is not a collective understanding of how the collaboration can work, and many behavior analysts proceed unethically (although unintentionally)
  1. 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
    1. will, and do, consider their history of trauma as something that informs everything I will do for them
    2. will still be practicing behavior analysis, but from this specifically informed perspective
    3. 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

  1. including professional educators, school psychologists and therapists who have attempted collaborations that failed because clients’ trauma was overlooked or the practices were ineffective
  2. 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
  3. or people who haven’t had ANY experiences with behavior analysis (in my practice this includes people from these groups):
    1. Lawyers and courts
    2. Court appointed special advocates
    3. Social workers
    4. Trauma therapists
    5. Foster families and adoption agencies

Dreaming of the future

My goals include that one day in the near future,

  1. 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.
  2. 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
  3. There are multiple funding streams to readily serve the population (examples: foster care, social workers, etc)
  4. 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.

CEU stands for Cusp Emergence University!

13 Tuesday Nov 2018

Posted by in About, BACB CEU, Behavior Analysis, boundaries of competence, CEU, continuing education, Education, ethics, learning, resources, risk analysis, risk assessment, teaching behavior analysis, teaching ethics, trauma, trauma-informed behavior analysis, Uncategorized

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Need training for your team in trauma-informed behavior analysis? Cusp Emergence University has launched! 

Come check out the site, sign up for one of Dr. Kolu’s courses, or just have a look around.

While we’re beta testing, save 15% on 3 CEU’s in a 2.5 hour continuing education course (Introduction to the Ethics of Trauma-Informed Behavior Analysis).

This course is for intermediate audiences interested in learning more about the ethics of trauma-informed behavior analysis, or using behavior analysis to provide responsible, evidence-based and sensitive support to individuals whose backgrounds include early or serious adverse experiences. Take this course to prepare your practice and team and plan for the increased risks associated with this population. BACB certificants receive your certificate upon completion of the course, which includes quiz questions to help keep you engaged. Course includes 2 ethics CEU’s.

DISCLAIMER: Dr. Camille Kolu of Cusp Emergence is a Behavior Analysis Certification Board (BACB) approved ACE provider. Advertisements for new continuing education opportunities (per the board requirements) will often be placed here. Check cuspemergenceuniversity.com for the full details, to enroll in courses, or to learn more about the continuing education opportunities provided.  The BACB does not endorse any individual courses.

Come back to the tab Cusp Emergence University, or check out CuspEmergenceUniversity.com  any time for updates on courses in development.

Dr. Kolu of Cusp Emergence interviewed by Awake Labs

19 Friday Oct 2018

Posted by in adults, Behavior Analysis, children, Community, data, Education, job aids, resources, trauma, trauma-informed behavior analysis, Uncategorized

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This post is part of the series on Trauma-Informed Behavior Analysis by Dr. Camille Kolu, Ph.D., BCBA-D.

TIBA quote

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!  

https://awakelabs.com/

 

Spotlight on team role: CASA (Court Appointed Special Advocates)

07 Friday Sep 2018

Posted by in Behavior Analysis, CASA, children, collaboration, Community, Court Appointed Special Advocate, Education, ethics, resources, Uncategorized

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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:

http://www.casaforchildren.org/site/c.mtJSJ7MPIsE/b.5301295/k.BE9A/Home.htm

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!)

https://casa17th.org/

Read about CASA in the news, with stories about topics like how to become a CASA…

https://www.caller.com/videos/news/2018/07/12/how-become-court-appointed-special-advocate/35522163/

or read from the perspective of a judge whose decisions are informed by their work:

http://www.sj-r.com/x1374045505/Court-Appointed-Special-Advocate-program-history

Find the Behavior Analysis Certification Board Compliance Code here:

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

 

 

 

 

 

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 →