Category Archives: ethics

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/

 

 

Beyond My Current Competence

20 Tuesday Mar 2018

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Resources

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

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

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

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

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

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

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2686995/pdf/bhan-32-01-85.pdf

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

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2223147/pdf/bhan-29-02-161.pdf

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

26 Monday Feb 2018

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

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(Part 12 of a series of posts about Trauma-informed behavior analysis by Dr. Teresa Camille Kolu, Ph.D., BCBA-D)

If you’re a behavior analyst, perhaps you read that title as “Is it behavioral to treat reactive attachment?” or “is it appropriate to use behavior analysis with a person who has been diagnosed with reactive attachment?” Perhaps you are really wondering, “is there anything I can do as a behavior analyst to help someone who has been affected by reactive attachment disorder?”

These are all good questions. First, to pose the problem another way, and to see the depth of the controversy, let’s go over some other observations I’ve heard, from mental health therapists to educators to families to BCBA’s: “Behavior analysts shouldn’t mess with reactive attachment.” “Kids with reactive attachment disorder don’t respond to behavior analysis.” “Families (or educators) whose children (or students) are suffering after reactive attachment related diagnoses can be harmed by or mistreated if people use reactive attachment.” “Reactive attachment is not a behavioral term and shouldn’t be treated with ABA.”

Now if you’re a longtime blog reader, you’ll find other ways of addressing these questions elsewhere on this blog. (I especially like talking to educators, family members and staff about what to do when praise doesn’t work, reminding us all that behavior is INDIVIDUAL, trauma-informed behavior analysis might look VERY different than that old discrete trial program you saw in college, and behavior analysis is not one cookie-cutter bag of tricks.) But I continue to hear questions about it, especially from educators, family members, and hospital and day program professionals faced with supporting the “toughest” cases. Continue reading →

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

02 Monday Oct 2017

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

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

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

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

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

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

Trauma-informed behavior analysis, Part 4: On terms (Is “trauma” behavioral?)

08 Tuesday Aug 2017

Posted by in adults, Behavior Analysis, children, Early Intervention, ethics, supervision, teaching behavior analysis, teaching ethics, trauma, Uncategorized

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This article is the fourth installment in a series on trauma-informed behavior analysis, by Dr. Teresa Camille Kolu, Ph.D., BCBA-D.

Is “trauma” a behavioral term?

“Trauma” is a buzzword lately. As several people recently noted on behavior analytic forums, it seems as though schools and other entities are requiring “trauma-informed care” from people tasked with providing behavioral interventions, yet it isn’t clear whether trauma actually presents as anything different than the reinforcement history, or a client’s past, that would be explored routinely in any old behavior assessment.

On a recent facebook post in a behavior analytic group, one person posted, “Trauma”, “trauma-informed”, etc, is [just] the new buzzword to get grant funding and sell product”. Another poster chimed in, “Trauma? What’s the behaviors [sic] of concern? What’s the function?” This seems to imply that if we know the current function of behavior, what more do we need to know? It suggests that the resulting treatment path is likely to be no different than that for a “typically developing child” of the same age and an apparently similar behavioral repertoire.

The implication in the social media posts above seems to be, “what’s the big deal?” In other words, trauma is thought of as some in the behavior analysis community as simply another sexy concept that is meant to sell and sound good, rather than being something critical to appreciate (and to suggest differential treatment based on its presence or absence).

As a behavior analyst who has treated children and adults exposed to serious and adverse childhood experiences, I have come to appreciate that the current function is NOT the only important thing to know before treating someone’s challenging behavior patterns, or helping an adoptive parent cope with challenges a mental health therapist might call “reactive attachment”.

So what’s a BCBA to do? Continue reading →

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.

 

Ethical Friday presents: The power of a Worst Case Scenario

04 Friday Aug 2017

Posted by in adults, Behavior Analysis, Community, ethics, job aids, risk assessment, safety skills, supervision, teaching behavior analysis, teaching ethics, Uncategorized

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Picture the worst that could happen.

Can you even imagine it?

And if you’re a seasoned therapist or behavior analyst, how do you communicate about this with your students and supervisees, who almost certainly can’t really go there?

If you’re like many of us, you don’t know what you don’t know. Suppose a client wants to gift your staff a gourmet coffee gift card, or a mother wants to step out quickly to get her dry cleaning. “It’s a five minute drive, I’ll just be a second”, she calls, as you work with her child in an upstairs therapy room. “No problem”, you start to call… but your ethics bone starts to tingle. Surely you’re over-reacting. What, if  anything, could go wrong?

When the worst case scenario relates to our vulnerable clients affected by trauma, the consequences may be even more dire– and yet, those who haven’t faced the possibilities may not recognize the dangers.

Should I accept this client in foster care with severe challenging behavior and a history of abuse although I have never treated similar cases? Should my agency supervise our new BCBA to take on a new trauma case (we have funding, after all) when we haven’t experienced this situation?Danger sign

For those of us tasked with supervising and teaching others, or working with families, we can help students, supervisors or parents picture the worst case scenarios so they can better prepare for, predict, and prevent dangerous outcomes. The Compliance code helps give guidance and rules that we follow, but for those of us who have NOT encountered situations that make us keenly aware of the reasons for these, some of the code items may seem “nit-picky” or unreasonable, and may be disregarded in a dangerous way.

To support our own cases and our supervisees where it counts, we must have a wealth of experience, stellar training that exposed us to a variety of worst case outcomes and possibilities and some solutions, or a great imagination- and a few good teaching and documentation tools.

I get a new wake up call every semester I teach ethics students about the origins of Behavior Analysis’ Ethics Code, which was spurred in part by atrocious, life changing and widespread abuses by those doing “behavior modification” in recent decades.

When I ask “what do you think? Could those things ever happen here?”, Continue reading →

Trauma-informed behavior analysis, Part 2: Arranging a supportive behavioral environment

03 Thursday Aug 2017

Posted by in adults, Behavior Analysis, Behavioral Cusp, enriched environment, ethics, supervision, teaching behavior analysis, teaching ethics, trauma, Uncategorized

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(Continued from Part 1 of Trauma-informed behavior analysis series by Dr. Teresa Camille Kolu, Ph.D., BCBA-D)

pencil_three years old (2)

Part 2, Engineering Supportive Environments

On arranging the environment

What does it mean to arrange the environment in a preventative way? This means to think about everything someone needs, and how they get it or communicate that they need it. After we consider this piece, we see holes in the behavioral environment.

If these holes go unfilled, the person will likely do whatever they need to do to fill them, often in a way that is ultimately unproductive and painful for themselves or others.

In a way, everyone is doing the best they can, all the time.

So in considering what someone needs in advance, we can find ways to plug in something helpful where it is needed, in a preventative way. This means that before someone needs something, an observant caregiver or friend may recognize the need is coming, and begin to set up the surroundings so that need is being filled. Before someone falls in the well, we fill up the well with concrete and make it so that they cannot fall in — even if they step right on top of it. For example 1 in Part 1, the client who was left alone in the dark is given preventative repertoire building, and taught skills that help her to cope each night with the coming darkness. Her caregivers are taught new repertoires, learning to announce their presence and ask her permission before entering; to problem solve with her instead of forcing the next event on her; and to check in in a preventative way to see if she needs anything, instead of responding with force when something is already going wrong. Eventually, she learns to ask for help before it gets to a crisis, to soothe herself to sleep instead of showing agitation leading to support going to bed, and to problem solve by herself when about to face a known triggering event. Continue reading →