Category Archives: teaching ethics

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

02 Monday Oct 2017

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

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

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

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

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

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

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

18 Monday Sep 2017

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

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

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

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

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

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

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

Can we treat behavior after this condition? Continue reading →

Do trials always make us stronger?

18 Friday Aug 2017

Posted by in adults, Behavior Analysis, Community, dementia, resources, teaching behavior analysis, teaching ethics, trauma, Uncategorized

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Sometimes I write of success; of hope; of happy endings.

These are notable in part because so much of the time, the families with whom I collaborate are those whose children probably won’t learn to talk or bathe themselves, or whose middle aged children might die in the mental hospital, or whose children might never overcome their meth addiction—or women who, like me, wonder if their infertility might be lifelong.

And by itself, merely “facing a challenge” doesn’t do anything.

In a cruel twist, those facing stressful and often life-long battles also encounter the most unhelpful and banal clichés that range from “not comforting” to insulting or humiliating. They often come from well-meaning people who haven’t walked a mile in the moccasins of those they are trying to help. I’m sure I’ve been guilty of this and that we all will be again.

But who cares about words. The interaction between a speaker and listener, and the actions of people, matter much more. It’s not what I say in a challenge that matters, compared to what I do. I’m reminded of Ogden Lindsley’s quip that “if a dead man can do it, it ain’t behavior”: I guess a dead person can face a problem. But can he solve it?

Maybe I don’t get stronger merely by facing challenges.

In fact, perhaps I become softer, more tender.

I cry more easily.

I empathize more, and longer, with the parents who struggled for 15 years to have a child often to learn that their expensive and long-prayed-for baby has life-threatening and life-long diagnoses.

If I’m not stronger, at least I’m listening more.

And I notice something else a dead person can’t do:

Whatever skills I practice become more fluent.

I listen and get better at listening.

I empathize and gain fluency at showing empathy.

I help, and gain skills in doing helpful things.

I care, and continue to care.

And I share and feel uncomfortable, and become more comfortable at being uncomfortable.

(Sorry, behavior analysts, I’m not sure if that last one was an actual “behavior”. Similarly, I’m sure a dead man could do this one too, but it took me lots of practice to finally become quite skilled at staying calm while having my blood drawn. I would like to stop practicing now, I’m fluent, thank you very much.)

Many parents of my clients with low functioning autism, or the grandparent clients who are raising their great-grandchildren while multiple generations in between are in jail or recovery, tell me that they are tired of being called heroes. That they are simply doing the best they can, all the time, like you or me.

That often they still wish they could do more or do it better.

As I help clients – such as those whose loved ones have dementia – I discover more and more that our trials are universal, although many of them seem so foreign to young people (and to inexperienced behavior analysts in the helping profession).  Lately I have been developing tools that seem so simple, yet also seem helpful to so many different clients, like this Resource_Orienting statement tool for a loved one who is distressed and disoriented.

Whatever tools we use, what matters seems to be to keep going—and to keep holding someone’s hand when it matters.  Granny and PaPa walking.jpg

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

10 Thursday Aug 2017

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

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

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

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

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

  1. Update your team’s FBA practice.

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

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

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

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

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

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

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

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

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

I’m listening. Contact me any time.

 

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 →