Now that the annual conference for ABAInternational is past (whew!), Cusp Emergence is excited about upcoming webinars and online conferences (New Hampshire and FABA, I’m looking at you!). First up is a partnership with Connections-Behavior.com: We will look at trauma-informed behavior analysis in two parts, on June 1 and 15. Register here for this CEU opportunity!
Behavior Analysis, Aging, Trauma, and Supervision (or BATS, in honor of Dr. Janet Ellis).
This is the 18th article in a series on Trauma-Informed Behavior Analysis by Dr. Camille Kolu, BCBA-D. It includes something new that we have been asked about: Companion notes for students and supervisees working through this information with the support of their supervisor.
I heard Jon Baker give a great talk on advances in behavioral treatment of gerontology the other day at COABA. It made me think of my students at the University of Colorado Denver and our supervisees. (There was also a fantastic talk on supervision and feedback by the incomparable Ellie Kazemi, whose book on supervision is out now). When they ask about clients other than autism who have benefited from applied behavior analysis, my supervisees are usually excited to read stories in which ABA changed the lives of people with dementia, brain injury, medical needs, and more. For example, an article from Baker (2006) Continue reading
This is the 17th article in a series on Trauma-Informed Behavior Analysis by Dr. Teresa Camille Kolu, Ph.D., BCBA-D.
What did you do when you saw this picture? Chances are you experienced some additional events beyond just “seeing it”. Did you jump? Experience an increase in your breathing rate? Use some choice verbal behavior? Avert your eyes? (And are you prepared to read on? Fair warning… there’s a snake coming up).
Seeing with fresh eyes
I noticed a couple of things about our culture, and fear responses, this past week.
My young daughter’s love for flap books—the kind where you pull back a piece of paper to reveal something—knows no bounds. So she was instantly drawn to a tattered old library copy (apparently she shares this love with lots of peers) of “Buzz Buzz, Baby”- with poorly rendered babies exploring “bugs”. Around the third page the baby pulls back a web flap to unveil, in the book’s words, “EEK! The itsy bitsy spider!”
Whenever I read the book to her I leave out the “Eek!”.
I think she can come up with that on her own, if she happens to, although chances are she’ll get it from me in a non-mindful moment. (In the 1980’s Cook and Mineka did a classic study in which infant monkeys “acquired” a persistent fear of snakes by watching their scared mothers encounter a snake).
Now that we’ve moved out to the country, we encounter our own “Itsy” (and many for whom that name is woefully inadequate) all the time. (I do recommend this thing called the BugZooka… it does work really well, if you like catch-and-release). Itsy and I go way back, and not necessarily in a good way, although I always appreciate her beauty. But I still want to be warned before you text me her picture, dad.
This summer, one tenacious spider (pictured, top) built a web, over and over, in a windy area outside the kitchen, where we see it numerous times daily. The first few (ok, few hundred) times I nearly jumped out of my skin. When I remembered in time, I was very careful to breathe and compose myself before walking to the sink with my daughter, where I’d point out the spider cheerfully and sing (with all the hand movements) the requisite song. Before long she was signing the song herself. Next I noticed myself no longer jumping when I saw the spider.
THEN… one windy morning Itsy was gone. Gone!
I didn’t breathe a sigh of relief.
I was surprised and curious to feel a strange emotion… like MISSING. I missed her! Was she alright? Would she come back? (She was. She did).
With painful awareness that this is temporary, I often marvel that my daughter’s eyes are not only young… they are unconditioned. They don’t have a lot of pairings with events like scary movies about this deep primate fear, being bitten, or seeing spiders while a parent jumps and screams. They are fresh, curious, hopeful eyes.
Yesterday we chanced upon something rather larger than even the biggest spider. It was this old girl… fat and long, with ring upon ring adorning her useful brown rattle. Depending on my readers, maybe you’ll be happy that instead of grabbing a hoe, I called a guy I read about in my new community’s online forum… apparently this guy LOVES snakes. “ANY snake’s worth my time”, he told me as he jumped in his truck. 35 minutes later he had driven up to our homestead, hooked it and taken it. Now it’s in a quite different rattlesnake heaven than the kind I had sort of planned to send it… blissing out in a protected wilderness area up near Fort Collins, I’m told.
As he removed our snake into a large vented box and curiously counted the rings (while remarking on how huge it was), the guy’s face was composed; he exuded a strange calm excitement. Normally, the fear response to snakes and spiders is part of our biology. Evolutionary biology has several theories why it’s present even in infancy, and why it might have behooved our ancestral mothers to experience more arousal and get out of there to protect their young in the presence of these critters. I can’t help but wonder what this guy’s history is like. Why does he love something that most of us are scared of?
Kids with traumatic histories
If you’re an educator going back to school, many of your kids are coming in with an avoidance response, or a “get out of there!” escape response, ready to go. Some of them will use these responses in the most annoying ways, dropping all their work on the floor or crawling under desks when you announce the quiz. But some of them have a special background you can’t see. For some, they will use these “fear responses” when they encounter “triggers” that you and I do not think of as scary.
Why is that?
Well, the things that were there when they experienced really bad situations are now “paired”, living together in their past, the same way I smelled an old lady yesterday wearing my own granny’s soap and got emotional thinking about my dear departed loved ones. Or the same way you hear a certain song from your high school dance and think about that year, or that person, or that kiss.
And that’s not all. Psychology explains in anxiety journals why, if you’re a person with an intense “fear” or phobia of spiders, not only do you spot them more quickly and tend to see them where your peers might see other things, like mushrooms or flowers faster in the SAME PICTURE—but to you, they also appear BIGGER.
What can we do about it?
How can we help students show up for their education and get all the learning opportunities they can… even when the school, teachers, and peers accidentally give them “fear related” stimuli all day long? (While psychology explains partly WHY these pairings happen, behavior analysis does too, especially if you read some relational frame theory, learn about respondent conditioning, and take a long-term functional analytic approach. Behavior analysis also goes a long way in helping the helpers undo some of the damage, teaching kids to approach adults and “unpair” adult attention from it’s previously bad parts: if I’m a student who has been through neglect abuse, my teacher coming over to me to praise my “good behavior” might not be a welcome stimulus at first… and my teacher’s praise, as well-intentioned as it may be, might not work).
Cusp Emergence University has been hard at work getting the new online training course ready for educators, and behavior analysts who work in education. We hope to help you to start answering these questions for yourself and your students and teams. On Monday, September 30, our course “Education and Trauma-Informed Behavior Analysis” opens to a 7 day sale (use the code EDTIBA10 for 10 percent off this CEU opportunity). We’re providing BCBA’s and BCBA-D’s with 3.5 continuing education credits, and 3 of those are in ethics.
Sign up now!
Need training for your team in trauma-informed behavior analysis? Cusp Emergence University has launched!
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.
This post is part of a series on trauma-informed behavior analysis by Dr. Camille Kolu, Ph.D., BCBA-D.
When treating behavior concerns after trauma, we may find that clients exhibit risks to themselves, risks to their community, and risks to caregivers that should be documented. Why have behavior analysts sometimes turned a blind eye to documenting these risks? Read on to discover some common reasons I found in the field, and ways we can address them.
When it’s too risky to even consider the risks
Our field has adopted a Compliance Code which mentions the need to document risks. As an instructor for courses in a BACB-approved course behavior analysis course sequence, I use a textbook that provides sample templates for documenting and analyzing risks. And as a practitioner, I have found that my analysis or assessment of risk is almost always helpful to a case (as in some situations I’ll describe below), not to mention that it’s quick and simple it is to do.
Despite these facts, most behavior analysts I encounter do not analyze risks in any sort of written format. The behavior analysts around me range from BCBA-Ds to RBTs, and many have expertise and long careers. Why are we averse to documenting risks?
I have been researching the answer to this question for several years, and often the answer is “because I don’t have a good risk assessment”. So I made some and piloted them with different agencies, working through the problems of how to identify, define, document and mitigate the risks related to the populations with whom I work most closely. But at a recent training opportunity I received a different kind of answer, and I think it’s too important to keep to myself.
Some of the BCBA’s I talked to at that event were not documenting risks, they acknowledged, because it was just too risky.
At first it seemed counterintuitive. If I was providing a new document that made it easy to document several options, and the potential risks and benefits of each, wasn’t that inherently reducing the risk? No, it turns out. To many of us, highlighting a risk necessarily imposes some degree of liability.
We’ve faced this challenge before. In pointing out a problem we may become partially responsible for solving it, as some educators have learned the hard way when their schools are upset with them for discussing the observations of a student’s difficulties outside of the official process. This responsibility may carry a financial burden or create an unsolvable problem in a resource-poor area. And some pediatricians I know have mentioned the frustrating dilemma of being given a new depression screen for teens or moms, only to have nowhere to go with the results.
A new ethical responsibility is only as useful as your agency’s process to fulfill that responsibility, and procedures to support the people implementing the new responsibilities.
And in the discussion with the BCBA’s that day about risk documentation, I learned something really interesting. The specific language I used made a huge difference in their willingness of adopting a new procedure.
When I called it a “risk assessment”, BCBA’s were unwilling to adopt my new “assessment”, even if it was backed up by the compliance code and plenty of evidence and anecdotes how it has supported my work.
But when I called it a “risk versus benefit analysis”, they were willing to try.
“Risk assessment” is a loaded term that carries legal weight in many contexts.
On the contrary, the other term (“risk versus benefit analysis”) is something that I use daily, and that is simply a process of documenting and analyzing the several different options available, together with their respective potential risks and benefits. It’s called for by the Compliance Code (and discussed by Bailey and Burch in their Ethics text).
According to the Compliance Code, “a risk-benefit analysis is a deliberate evaluation of the potential risks (e.g., limitations, side effects, costs) and benefits (e.g., treatment outcomes, efficiency, savings) associated with a given intervention. A risk-benefit analysis should conclude with a course of action associated with greater benefits than risks.”
The Compliance Code mentions risks in several places. In 2.04b, we are to consider risks of performing conflicting roles (e.g., when we are clarifying third party involvement in services). In 2.09c we are asked to use a risk-benefit analysis as part of our process in deciding between different treatments. And in 4.05, we are asked to work with stakeholders to present the potential risks versus benefits of which procedures we plan to use to implement program objectives. 7.02 asks us to consider risks involved, when there may have been an ethical or legal violation by a peer. And of course, we consider the potential risks and benefits when doing research (9.02).
The Task List does not mention “risk” by name, but alludes to the process when requiring that we are required to be able to state and plan for the possible unwanted effects of reinforcement (C-01), punishment (C-02), or extinction (C-03), as well as behavioral contrast (E-07). Similarly, the Code makes it clear that we are to identify potential for harm with using reinforcement (4.10) and identify obstacles to implementing recommended treatment (4.07).
In my practice, the most efficient way to meet all these objectives and more, is to complete a risk-benefit analysis. I love to include sections on mitigating the risks I do identify, so that the team can make an informed decision about what resources, training, information or support they will need to implement the least risky option.
And a final benefit I’ve heard many stakeholders mention during this process (and typically I do the analysis as an open discussion in which they are involved and brainstorming), is usually stated like this: “I didn’t think we had any other options, but when we approached this with a goal to identify alternatives and the risks and benefits of each, we uncovered several more”.
The risk versus benefit analysis is something I document, add to a treatment plan or employee or client file or IEP, or simply something I share with the team in writing and in person to solidify systems support for my next move. Recently, the following situations were ameliorated by using a transparent risk versus benefit analysis. Outcomes included increasing appropriate funding; securing appropriate medications; identifying appropriate caregivers; funding appropriate training; and improving client satisfaction.
-what kind of residential facility would be most appropriate to move a client to
-whether to discharge a client now or later
-whether to use a cheaper program with fewer resources or a costly one with many
-whether to put a client in a foster home in a potentially risky but supportive situation
-whether to delay an assessment to have an operation
-under what conditions should we discontinue a client who violates our informal no-show policy
-what caregiver to select from several available
-how to appropriately include police contact in a plan in a way that reduced long term risks
-what medication to decrease and when
-whether to put a student in a restrictive school with more behavior support, or a less restrictive placement with more social interaction options
As you can see by the last two, sometimes these decisions are not cut and dry. They depend on the team and family input, and one family may weigh a given outcome more heavily than another. Everyone has a history. To do these analyses in a compassionate and open way is important, and sometimes we don’t agree. To involve high level stakeholders and funders is critical as well.
What are the risks of doing a risk-benefit analysis? Perhaps you’ll highlight more risks than you thought were there; perhaps you’ll have to take some responsibility for the outcome of your recommendations. But what are the risks of avoiding this important process? If you are certified, your responsibility as a behavior analyst “is to all parties affected by behavior-analytic services” (e.g., 2.02). So are there risks of not documenting risks? Sure. You could cause harm or be negligent if there is a known risk you didn’t plan for or discuss with the team. Just like there are risks, there are benefits too. Doing a good risk versus benefit analysis is certainly a helpful cusp for supervisors and behavior analysis leaders to acquire! Many times we have uncovered risks that can be totally avoided next time if we were to act now to change or solidify policies, or use preventative measures in the future. A risk-benefit analysis can be a wonderful contribution to discussing lessons learned.
There are more options to be uncovered. Go out there and find and document them!
Want a resource? Check out the 3rd edition of the Bailey and Burch text Ethics for Behavior Analysts (2016), read more on Cusp Emergence , or check out a risk versus benefit tool (I like to do this on a whiteboard with my teams).
Convinced? Have a question? Drop us an email. And thanks for reading about this important topic. We’d love to see how YOU document and discuss risks!
(Part 14 of a series of posts about Trauma-informed behavior analysis by Dr. Teresa Camille Kolu, Ph.D., BCBA-D)
Connections between mental health and behavior analysis
This topic is always close to my heart as I work regularly in mental institutions, and as my business supports wellness practices that affect everyone—including those of us who need help prioritizing our own mental health. But it’s an especially important topic right now: May is Mental Health Month!
Sometimes my work involves conducting an assessment to see whether a client needs behavior analysis, or mental health support, including ways to thrive with a history that includes mental illness. In other words, sometimes (many times!) directly providing mental health support goes beyond my scope, and my job in those cases involves referring to other providers or more typically, collaborating with them. But instead of those cases, today we discuss some intersections between behavior analysis and mental health. If you’re board certified or licensed you’ll want to keep a copy of your field’s ethics code handy (here’s mine, as a BCBA-D). If you’re a family or team member wondering about these connections, read on.
No matter your certification, it’s never ethical to work completely out of one’s boundaries of competence. However, it’s also true that applied behavior analysis has supported individuals with mental illness concerns (including those with symptoms of challenges such as schizophrenia) since the field’s very beginnings. Young BCBAs without historical education in the full range of our field’s applications might have been surprised to see the transformation on some 1950’s psych wards of a population with various psychiatric disorders as patients changed from non-social and despondent individuals to interacting with their peers and their behavior analysts. They met goals they set for starting to take care of themselves again as they got dressed, talked more with peers, worked, visited families, and traded in tokens they earned for individual items they wanted to earn, such as a radio to keep in their room. In the earliest days of applied behavior analysis, Ogden Lindsley and colleagues used reinforcement schedules and behavioral apparatus to analyze psychotic behavior and to reveal that it was subject to operant mechanisms just like other behavior. Behavioral treatment of schizophrenia, in that area, became robust, effective, and almost commonplace. For example, Kurt Salzinger analyzed the verbal behavior of persons with schizophrenia and showed that it was related to discriminative stimuli and consequences of people around the patients (Salzinger and Pisoni, 1958, 1961). A later literature review of articles between 1959 and 1972 (Stahl and Leitenberg, 1976) showed that across 23 articles describing programs for psychotic and chronic mental patients, the individualized behavior programs were widely and substantially effective, producing large improvements in the behaviors that were targeted. History students might enjoy Stephen Wong’s “Behavior Analysis of Psychotic Disorders: Scientific dead end or casualty of the mental health political economy?” (Wong, 2006).
But don’t forget the important caution I mentioned while beginning this section: Without training and expertise and supervision in a given population, any work, no matter your field’s history, is still out of one’s scope. Even so, for those behavior analysts with a more limited history, there are still the vast literatures on the empowering use of self-management to change addictive behavior, manage anxiety, self-monitor triggering situations and select and strengthen one’s own coping skills. These are widely used and well researched. In fact, before there was ACT (or Acceptance and Commitment Therapy), there was self-management. (For a good introductory text on behavioral self management see Alexandra Logue’s Self Control: Waiting Until Tomorrow for What You Want Today). Wherever social contingencies matter, behavior analysis can generally help.
Although using behavior analysis in mental institutions generally fell out of favor decades ago, it has been markedly effective in my last few years of work helping others with mental illness learn skills needed to transition to meaningful lives outside the institution, sometimes after decades in those facilities (or years in group homes, foster homes, and inpatient units). Here, the behavior analytic skills of systems support and functional assessment have been useful for teaching teams how to support individuals who had nearly given up on finding a more permanent home.
Collaboration with providers
What someone needs most and first is sometimes collaboration and support, not an intensive 1:1 ABA session. For my clients with mental illness or mental health needs, it has been extremely helpful to:
-get the entire team on the same page
-look at what has been going wrong (e.g., review incident reports and challenges that have repeatedly plagued the attempts to help the person)
-discover what the team wants
-find out what has been a recurring problem? What is keeping the client from the life they want? Who cares about the client and what skills are missing?
-establish communication protocols for the team
-find out what behavioral and other strategies were already in place and whether or how they are working (Often, a team has been using a token system, or behavior plans, or consequences, or attempts to change behavior using antecedents or instructions and modifying motivation, before a behavior analyst ever entered the picture. Our job is to document what has been done and how this has worked; along the way we can often help an entire agency understand how to make their routine interventions more ethical and effective.)
When I have gathered all of that information plus interviewed team members and my client, documented my review of reports, other supports, and the contributions of medical, historical and childhood factors and the client’s and team goals, I have the makings of a behavior assessment and am able to begin sharing recommendations with the team. These recommendations may include more appropriate and consistent strategies, additional documentation of risks to the client and their community, and training on treatments and ways of interacting that may be more effective and helpful to the team and client than what has been attempted in the past.
Stop for a minute: does all of this suggest that a client is necessarily out of a behavior analyst’s scope of service because they struggle with mental illness? No; furthermore, nothing suggested here discounts the important roles of mental health counselors, psychiatric nurses, social workers, psychiatrists and psychologists, and the other members of the treatment team. If anything, my past several years of work has taught me that a good collaboration has usually resulted in making their roles work even better.
Another way behavior analysis is involved in mental health is the important need to protect our own mental health.
In our line of work, we must be able to respond compassionately and calmly to burned-out staff or clients whose behavior “targets” us, perhaps physically, emotionally, or all of the ways a staff person can be targeted or hurt in the line of work. A recent and excellent training on ACT for intellectual disability shared studies in which it helped reduce staff burnout and increase engagement with clients. These two are related, for when I am healthy and calm I can respond more appropriately and consistently to my clients. Since my clients are often staff, it also helps when I train them in techniques that will help them maintain consistency and calm when they are confronted with the daily grind of their own jobs.
One of the simplest yet most effective interventions is arranging an enriched environment—it grows neurons, increases social behavior, and supports virtually every population. Although it can take less time than waiting and intervening in crises, it is not something an inpatient staff can or wants to do when burned out.
When I teach staff how to stay calm and respond calmly and with preventative input (e.g., my preventative schedule or NCR approach), this is often a burnout-protective approach. It IS behavior analytic, but it’s not complicated.
Connections no one planned
Mental health and ABA are also connected accidentally, when a mental health therapist learns their client is receiving ABA, or a behavior analyst learns their client has also been diagnosed (e.g., anxiety, bipolar disorder, PTSD, or others). In these moments we are forced to look at the connection: what do we do to support the client? Ethically, perhaps we should reach out to learn how the family feels about collaboration; maybe the psychiatric team would love to hear how we are supporting behavior change at home or school and how the data change when medications are changed; or maybe there are important risks to document, or helpful suggestions to make that would help the team stay on the same page. Yet often one or more parties says “not my role!” and makes no efforts to implement connected support. Notice again this is still not suggesting to go outside your role, but to work more collaboratively with others as much as it is appropriate (e.g., Ethics Code 2.03a-b).
Taking care of myself
Finally, here are some other simple behavior analytic strategies that help me manage and protect my own mental health so I stay focused and available to bring my best self to client interaction.
Manage my schedules of reinforcement
I carve out time for myself daily- I make time for tea, breakfast and stretching- all important preventative appetitive things I need to approach regularly.
Set up and honor stimulus control strategies to decrease my exposure to stressors
-Take off email notifications on my phone: Sure, you don’t have to answer them, but how many times has one subject line told you about an upcoming stressor, increased your heart rate, or interrupted your use of coping skills or important family time?
-Limit checking email to when you are prepared to respond (not necessarily by hitting reply, but read it and respond by writing a note you’ll save and send later, perhaps). (If scrolling through my account before bed I notice an inflammatory email, I can pause and return tomorrow. I recently practiced this—stopped reading past the subject line until the morning, and first meditated and had breakfast. It was still upsetting but I found that I was able to answer it and move along).
How do you think behavior analysis and mental health are connected? We love to hear your input, stories or questions.
Selected references and resources
Anthony Biglan, Georgia L. Layton, Laura Backen Jones, Martin Hankins and Julie C. Rusby, The Value of Workshops on Psychological Flexibility for Early Childhood Special Education Staff, Topics in Early Childhood Special Education, 32, 4, (196), (2013).
Lindsley, O. R. (1960). Characteristics of the behavior of chronic psychotics as revealed by free operant conditioning methods. Diseases of the Nervous System (Monograph Supplement), 21, 66-78.
Lindsley, O. R., & Skinner, B. F. (1954). A method for the experimental analysis of the behavior of psychotic patients. American Psychologist, 9, 419-420.
Salzinger, K., & Pisoni, S. (1961). Some parameters of verbal affect responses in schizophrenic subjects. Journal of Abnormal and Social Psychology, 63(3), 511-516.
Salzinger, K., & Pisoni, S. (1958). Reinforcement of affect responses of schizophrenics during the clinical interview. Journal of Abnormal and Social Psychology, 57(1), 84-90.
Stahl, J. R., & Leitenberg, H. (1976). Behavioral treatment of the chronic mental hospital patient. In H. Leitenberg (Ed.), Handbook of behavior modification and therapy (pp. 211-241). Englewood Cliffs, NJ: Prentice-Hall.
Stephen Wong (2006). Behavior analysis of psychotic disorders: Scientific dead end or casualty of the mental health political economy? Behavior and Social Issues, 15, 152-177.
(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
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.
Behavior Analysis Certification Board BCBA and BCaBA Task List, Fourth Edition:
Behavior Analysis Certification Board Compliance Code (2016):
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/
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!
LeBlanc et al. (2012) on expanding the consumer base for behavior analytic services
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):
Article on “values” in behavior analysis using the ACT framework:
Article on ACT and behavioral activation related to depression and avoidance:
acquisition, acquisition predicts extinction, behavior analysis, behavior cusp, extinction, previous learning affects new learning, trauma, trauma-informed behavior analysis, variability, variability during acquisition predicts variability in extinction
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 a 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
For readers following our ongoing series on treating behavior affected by previous adverse experiences (e.g., trauma) from a behavior analytic perspective, you may have noticed a few key concepts embedded in the articles and stories I have shared so far. One of these key ideas is this:
After trauma was present in a child’s life, their behavior may seem to respond a bit (or a lot) differently to everyday behavior management strategies.
Because this is such an important idea, I want to say it a few different ways to help you identify with different audiences and members of your collaborative team.
A parent might say, “I don’t know why, but in my 20 years of parenting kids, many who had disabilities and many who were typically developing, I’ve never had a child who just didn’t respond to my regular parenting skills – this child doesn’t respond the same, and not only does my normal parenting seem to not work, but it feels like I’m actually making it worse when I try to help.”
(Empathy red flag: Remember my suggestion to go to parenting or adoption or foster care groups and to listen hard before you try to help? Any behavior analyst knows to first “do no harm”, and it gets real, right here, when we try to help first by “doing only what we normally do” after someone experienced certain kinds of aversive and “traumatic” experiences.)
A special educator getting his behavior analytic certification new to “kids who have been through abuse or neglect” might say, “it’s so weird how the PBS (positive behavior support) and class-wide token system techniques work on my whole class, but they just don’t seem to impact this student at all; I feel like he doesn’t care, and I can’t seem to get through to him”.
A law enforcement professional new to this population might say, “It’s strange how the mother who called us seemed like she was in crisis and the child was about to commit murder, but when we got there the child seemed super calm and talked to us like nothing was wrong; I’m thinking it might be the parent who has mental health issues.”
(Above, this law enforcement example is a red flag for indicators of possible “Reactive attachment” issues that will be discussed in some upcoming articles. It might sound strange to a behavior analyst, but “attachment” is an idea that can be translated and discussed with social workers and caregivers to make sure that the client is receiving appropriate support. Responding oddly to praise is just one of the indicators of a past challenging history, and telling vastly different stories to different adults can be another.)
A behavior analyst might say, or at least agree, that someone’s behavior responds differently to social stimuli after a series of difficult, life-changing and aversive experiences that occurred with previous caregivers.
And a behavior analyst familiar with using preventative schedules and comprehensive historical assessments to support a client after serious aversive experiences might say, “We need to document what stimuli the person was exposed to in their conditioning history, and how socially delivered stimuli affect their current behavior stream. We need to prioritize the teaching agenda for the caregivers, parents, and teachers, to make sure they know how to deliver preventative schedules [instead of doing the everyday adult training agenda like teaching people to praise appropriate behavior; we know that because of this person’s history, praise may not function as a reinforcer, and may result in worsening behavior over time, if we are not careful about how and when it is delivered].”
It’s important to point out that this article is not about how praise is not a good idea.
In fact, praise is just a social interaction that involves pointing out what was great about someone’s behavior, and it can be as simple as calling out a behavior when a child tries it for the first time (“Hey, you helped out without asking when we cleaned up the room; I bet Ms. Tilly was super happy to get some help. Did you notice how she smiled at you when we left? You’re a part of this school family and we’re so glad you’re here.”)
It’s also not about how to deliver praise effectively or why we praise or how to fade out praise. (If you’re interested in that, check out research on the subject in the Journal of Applied Behavior Analysis or our Why we praise handout).
It’s really about how something—a parenting practice, a behavior management strategy, an educational plan—works, given someone’s history. Often this is in addition to how a behavior functions in the moment.
It’s about individualizing our strategies (which can only occur after appropriate assessment). Praise should be a tool that waters the flowers you want in your garden. If you accidentally dump fertilizer on something you don’t want to grow, what happens? What if praise isn’t like water to a flower, but a weed-killer that will stunt its growth, because of the person’s history, and how it was paired with other stimuli in their repertoire?
Sometimes we jump in before assessing the history.
Clients exposed to disruption in their early learning histories just don’t respond “typically” to praise.
Praise is not magic.
It’s just another stimulus that occurs in a social context.
By definition, it is delivered by a person, meaning it has a social conditioning history.
For some of us, it was just a signal or pre-condition for bad things about to happen.
Unlike in happy homes, for people who have been through abuse, the history of hearing praise (or hearing adults talk to a child) might not be pleasant, or predictable.
Similar to how the history of caregiving was not necessarily predictable or always pleasant, so we can’t expect that learning to trust a new caregiver, teacher or adoptive parent, or starting to enjoy their praise, or follow their helpful suggestions and instructions, will be easy or predictable.
How can we help?
When we’re lucky, sometimes clients use their words to tell us. My 20y old client who had been through abuse (and was living in a jail setting where she felt “safer” than going home to live with people who had abused her in the past) reminded me, “Dr. K, you already know I don’t respond well to compliments.”
When they’re not able to use words, even if they can sometimes speak, clients use their behavior to tell us that they don’t feel safe, or that praise is uncomfortable or that adults are historically not reliable signals of good things.
P.S. Why is “risk assessment” checked as a category or tag for this article? If we don’t assess the risks for using interventions in a case that involves “trauma”, we risk using or recommending a strategy that would work in 90% of your other cases but might increase challenging behavior in this one. If you’re a behavior analyst, you’re already concerned with following our field’s ethics guidelines related to risk assessment.