A few years ago, Cusp Emergence began to notice something. The folks at my trainings were often RBTs! Registered Behavior Technicians (RBTs) are certified by the Behavior Analysis Certification Board (BACB); they work on the front lines doing some of the hardest, lowest-paid jobs in our field, and they get the brunt of the most difficult behavior. (And you know I don’t refer only to behavior emitted by clients; we all realize that staff and caregiver interactions can contribute to the most challenging parts of our work weeks).
You’d think all this makes an RBT the most respected, cared-for person in the organization. Surely they are valued like nurses, revered like clergy, paid like winning quarterbacks, and trained like the champs they are going to have to be for those marathon sessions in clients’ homes, the community, and the clinic where they are providing the majority of hours you submit to insurance for compensation.
But that’s not the case. In fact, we’re guilty of it too: Cusp Emergence University has never recorded a “for-RBTs-training”….
That’s all changing with our new series, Professional Development for Dyads.
What’s a dyad?
A dyad is two people. Maybe the two people are related through their roles, jobs, family (like when we address a caregiver and their baby in early intervention, or a couple in a relationship). In this case, we want to address the RBT and their supervising BCBA (although each of them is welcome to take the course on their own).
Social media tempts and reinforces our behavior of crowdsourcing (and even outsourcing) our decision-making in difficult situations. In fielding or asking questions on facebook, tiktok, Instagram, or reddit, you’ve seen the following situation:
An RBT or BCBA brings up a tough situation and tries to crowd-source the answer to “what do I do?”. These are not always unique situations; many of them are familiar or someone has faced them before. And it is helpful to gain perspective if someone else has.
However, how many times do we vet each suggestion received, evaluate their source as credible or not, and see if there is a precedent in the literature if appropriate? How much of the time do those suggestions take into account the individualized needs of our client… while protecting their privacy and avoid sharing identifying info on social media? And how often do we actually receive advice that goes against ethics, best practice, or the law?
How is this type of course different?
Provides differentiated instruction: In this innovative hour with Dr. Camille Kolu, a BCBA supervisor and their RBT supervisee hear about the same topic. But level-individualized handouts provide the exercises, tools, and questions to help the RBT learn and apply new information, while the BCBA learns from a supervision perspective how to help someone else to learn skills and apply the ethics code in practical ways.
Uses modeling: Addressing the dyad together allows us to model supervision skills and tools for the BCBA, while the RBT gains new skills that will benefit them and their clients and team.
Quickly (in 1 hour) adds value to your team’s repertoire: The skills we teach in this series are all skills that are valuable for the clinician, client, and the team, and we select only skills that are most requested in our in-person trainings. The first course in the series teaches Risk Versus Benefit Analysis.
Unlike asking the internet what you should do in a tough ethical situation, conducting an individualized risk versus benefit analysis has many benefits.
The first and most obvious benefit is its outcome: doing the RVB results in several potentially satisfactory alternative options. And I love the fact that it can bring teams together, puts stimulus control over tough conversations, honors and documents voices that were not considered before, and leads to the kind of practical documentation we are asked to keep in the ethics code. (And, yes, we share a tool for that!)
So, what does this course do?
Through this 1 hour we spend together, RBTs learn many of the skills needed to encounter a behavioral cusp: completing their very own risk versus benefit assessments when faced with difficult situations.
What do RBTs do in these courses? RBTs watch short videos, take quizzes, learn about ethics connections to their code, read their quiz feedback, answer thought questions, download and try out tools, and do exercises.
What does the supervising BCBA do? BCBAs do all of the above, but they also receive article suggestions and thought questions; notes and exercises on ethics connections, templates adapted to BCBA Ethics Code requirements, and readings and discussion questions just for them.
Article in series on TIBA (trauma-informed behavior analysis) by Dr. Teresa Camille Kolu, Ph.D., BCBA-D
For many people including up to 90% of autistic women, our behaviors, moods, and medical symptoms worsen every month in the luteal phase of the menstrual cycle. But why? This may baffle even the most highly trained OBGYNs and behavioral scientists, let alone parents, caregivers, staff, and clients receiving behavioral services.
To Dr. Kolu, behavioral seismology is the scientific study of cyclical changes in a person’s experience that result in predictable (and potentially damaging) disruptions in an individual’s behavioral environment. Predictions about cyclical needs could be used to reduce the risk of damage and injury to clients and others related to hormone-behavior interactions. People can experience an increase in behavior needs, emotional needs, medical needs, and challenging interactions between all three, but it can help to know and be able to predict when they will be most at risk.
For individuals assigned female at birth (and relevant to anyone who loves, cares for, or conducts behavioral support for someone with these characteristics) , Dr. Camille Kolu discusses these four distinct behavioral risk profiles as ways to help make sense of the predictable disruptions that can occur regularly and monthly for up to 2 weeks at a time (as in PMDD) or for several years (as in perimenopause). The 4 risk profiles include the following:
PCOS or polycystic ovary syndrome
PMDD or premenstrual dysphoric disorder
Perimenopause and
PME (premenstrual exacerbation).
These 4 profiles are each accompanied by a pdf fact sheet downloadable as a resource in the new course on Behavioral Seismology from Cusp Emergence University. In each PDF are characteristic risk factors; biological signs; medical, behavioral and other symptoms the risk profile makes more likely; a to-do list for providers; and notes on expected interactions between behavior and the medical diagnosis. For instance, in PCOS, a client in behavioral services might experience self-injury related to the predictable pain during ovulation or food related behavior challenges that are related to the characteristic insulin resistance. In PMDD, a client in behavioral services who also has autism might experience sudden explosive outbursts in the second half of their menstrual cycle.
What are some of the benefits of becoming a healthcare or behavioral provider more informed about behavioral seismology?
Information can help to demystify behavior needs, as we put them into the context of an individual suffering with medical issues that need treatment. As a case example, one of Dr. Kolu’s patients had a diagnosis of PCOS (polycystic ovary syndrome) and took related medication. However, the behavioral team thought of that diagnosis as completely divorced from their behavioral treatment, and had never been trained on (or requested support to learn) what specific behaviors were anticipated and when they would get worse. As a result, the behavioral team had written goals that were inappropriate and inflexible. In most of the risk profiles we discuss in the Behavioral Seismology course, behaviors improve for the first two weeks of the cycle, when reinforcers are more potent. In the luteal phase of the cycle, a behavior targeted for reduction is likely to come raging back, as several things occur: one of the most significant is that aversive stimuli are temporarily more aversive! Another is that conditioning processes (such as extinction) are affected by hormone levels; for someone with trauma, the things we call “conditioned fear stimuli” or reminders of bad things that happened in the past, seem more present and potent during the luteal phase. Could these changes affect behavior? Absolutely! What if we ignored these biological realities and expected clients to simply do better and better on their goals in a linear trajectory? Could this be demoralizing for them and frustrating for caregivers and uninformed providers?
We can be more flexible in goal writing, more appropriate in support, more predictive in funding needs, and more compassionate in treatment, when we truly take someone’s medical needs into account. This is the point of the Behavior Analysis Certification Board (BACB)’s Ethics Code Item 2.12. For providers interested in taking that code seriously, Behavioral Seismology (4 CEUs total) provides an ethics CEU focused on treating behavior in ways much more contextually appropriate.
Other things you’ll find in the course:
4 pdf risk profiles
An aversive stimulus tracker template (and filled out example)
A Cyclical Needs Conversation Guide for providers
A tool called “Rethink Your Language” (using the example of how the word “aggression” can cause impactful changes in someone’s life)
Insulin Resistance Handout (with information about how this condition intersects with each risk profile discussed in the training)
Information on how autism intersects in surprising ways with several of the risk profiles (and a tool called “Acting on Combined Risk”)
A Cyclic Behavior Support Plan Template
The Cyclic Systems Support Checklist (for companies and teams making these changes in their processes)
A video script for the 8 videos accompanied by printable handouts
Full references for over 70 published articles (including ones by autistic providers on lived experiences of individuals affected by both autism and hormone-behavior interactions
Thought questions
Thoughtful intersections and objectives to apply ethics codes to understanding the ethical implications of information in each chapter
and much more.
Want to learn more? Take the course, contact Dr. Kolu to let us know you want to attend one of our live training sessions on Behavioral Seismology, or see the references below.
Beltz, A. M., Corley, R. P., Wadsworth, S. J., DiLalla, L. F., & Berenbaum, S. A. (2020). Does puberty affect the development of behavior problems as a mediator, moderator, or unique predictor?. Development and psychopathology, 32(4), 1473-1485.
Graber JA (2013). Pubertal timing and the development of psychopathology in adolescence and beyond. Hormones and Behavior, 64(2), 262–269.
Negriff S, & Susman EJ (2011). Pubertal timing, depression, and externalizing problems: A framework, review, and examination of gender differences. Journal of Research on Adolescence, 21(3), 717–746. doi: 10.1111/j.1532-7795.2010.00708.x
References for PCOS:
Cherskov, A., Pohl, A., Allison, C., Zhang, H., Payne, R. A., & Baron-Cohen, S. (2018). Polycystic ovary syndrome and autism: a test of the prenatal sex steroid theory. Translational psychiatry, 8(1), 136.
Dan, R., Canetti, L., Keadan, T., Segman, R., Weinstock, M., Bonne, O., … & Goelman, G. (2019). Sex differences during emotion processing are dependent on the menstrual cycle phase. Psychoneuroendocrinology, 100, 85-95.
Dumesic, D. A., & Lobo, R. A. (2013). Cancer risk and PCOS. Steroids, 78(8), 782-785.
Evans, S. M., & Foltin, R. W. (2006). Exogenous progesterone attenuates the subjective effects of smoked cocaine in women, but not in men. Neuropsychopharmacology, 31(3), 659-674.
Evans, S. M., Haney, M., & Foltin, R. W. (2002). The effects of smoked cocaine during the follicular and luteal phases of the menstrual cycle in women. Psychopharmacology, 159, 397-406.
Katsigianni, M., Karageorgiou, V., Lambrinoudaki, I., & Siristatidis, C. (2019). Maternal polycystic ovarian syndrome in autism spectrum disorder: a systematic review and meta-analysis. Molecular psychiatry, 24(12), 1787-1797.
Mulligan, E. M., Nelson, B. D., Infantolino, Z. P., Luking, K. R., Sharma, R., & Hajcak, G. (2018). Effects of menstrual cycle phase on electrocortical response to reward and depressive symptoms in women. Psychophysiology, 55(12), e13268.
Sakaki, M., & Mather, M. (2012). How reward and emotional stimuli induce different reactions across the menstrual cycle. Social and personality psychology compass, 6(1), 1-17.
References for PMDD:
Browne, T. K. (2015). Is premenstrual dysphoric disorder really a disorder? Journal of Bioethical Inquiry, 12, 313-330.
Ellis, R., Williams, G., Caemawr, S., Craine, M., Holloway, W., Williams, K., … & Grant, A. (2025). Menstruation and Autism: a qualitative systematic review. Autism in Adulthood.
Epperson, C. N., Pittman, B., Czarkowski, K. A., Stiklus, S., Krystal, J. H., & Grillon, C. (2007). Luteal-phase accentuation of acoustic startle response in women with premenstrual dysphoric disorder. Neuropsychopharmacology, 32(10), 2190-2198.Ford, 2012
Freeman, E. W., & Sondheimer, S. J. (2003). Premenstrual dysphoric disorder: recognition and treatment. Primary care companion to the Journal of clinical psychiatry, 5(1), 30.
Gingnell, M., Bannbers, E., Wikström, J., Fredrikson, M., & Sundström-Poromaa, I. (2013). Premenstrual dysphoric disorder and prefrontal reactivity during anticipation of emotional stimuli. European Neuropsychopharmacology, 23(11), 1474-1483.
Halbreich, U., Borenstein, J., Pearlstein, T., & Kahn, L. S. (2003). The prevalence, impairment, impact, and burden of premenstrual dysphoric disorder (PMS/PMDD). Psychoneuroendocrinology, 28, 1-23.
Kulkarni, J., Leyden, O., Gavrilidis, E., Thew, C., & Thomas, E. H. (2022). The prevalence of early life trauma in premenstrual dysphoric disorder (PMDD). Psychiatry research, 308, 114381.
Obaydi, H., & Puri, B. K. (2008). Prevalence of premenstrual syndrome in autism: a prospective observer-rated study. Journal of International Medical Research, 36(2), 268-272.
Protopopescu, X., Tuescher, O., Pan, H., Epstein, J., Root, J., Chang, L., … & Silbersweig, D. (2008). Toward a functional neuroanatomy of premenstrual dysphoric disorder. Journal of affective disorders, 108(1-2), 87-94.
Sacher, J., Zsido, R. G., Barth, C., Zientek, F., Rullmann, M., Luthardt, J., … & Sabri, O. (2023). Increase in serotonin transporter binding in patients with premenstrual dysphoric disorder across the menstrual cycle: a case-control longitudinal neuroreceptor ligand positron emission tomography imaging study. Biological Psychiatry, 93(12), 1081-1088.
References for Perimenopause:
Ambikairajah, A., Walsh, E., & Cherbuin, N. (2022). A review of menopause nomenclature. Reproductive health, 19(1), 29.
Arnot, M., Emmott, E. H., & Mace, R. (2021). The relationship between social support, stressful events, and menopause symptoms. PloS one, 16(1), e0245444.
Avis, N. E., Crawford, S. L., Greendale, G., Bromberger, J. T., Everson-Rose, S. A., Gold, E. B., … & Study of Women’s Health Across the Nation. (2015). Duration of menopausal vasomotor symptoms over the menopause transition. JAMA internal medicine, 175(4), 531-539.
Constantine, G. D., Graham, S., Clerinx, C., Bernick, B. A., Krassan, M., Mirkin, S., & Currie, H. (2016). Behaviours and attitudes influencing treatment decisions for menopausal symptoms in five European countries. Post Reproductive Health, 22(3), 112-122.
Cusano, J. L., Erwin, V., Miller, D., & Rothman, E. F. (2024). The transition to menopause for autistic individuals in the US: a qualitative study of health care challenges and support needs. Menopause, 10-1097.
Duralde, E. R., Sobel, T. H., & Manson, J. E. (2023). Management of perimenopausal and menopausal symptoms. Bmj, 382.
Guthrie, J. R., Dennerstein, L., Taffe, J. R., & Donnelly, V. (2003). Health care-seeking for menopausal problems. Climacteric, 6(2), 112-117.
Hamilton, A., Marshal, M. P., & Murray, P. J. (2011). Autism spectrum disorders and menstruation. Journal of adolescent health, 49(4), 443-445.
Hoyt, L. T., & Falconi, A. M. (2015). Puberty and perimenopause: reproductive transitions and their implications for women’s health. Social science & medicine, 132, 103-112.
Karavidas, M., & de Visser, R. O. (2022). “It’s not just in my head, and it’s not just irrelevant”: autistic negotiations of menopausal transitions. Journal of Autism and Developmental Disorders, 52(3), 1143-1155.
Kling, J. M., MacLaughlin, K. L., Schnatz, P. F., Crandall, C. J., Skinner, L. J., Stuenkel, C. A., … & Faubion, S. S. (2019, February). Menopause management knowledge in postgraduate family medicine, internal medicine, and obstetrics and gynecology residents: a cross-sectional survey. In Mayo Clinic Proceedings (Vol. 94, No. 2, pp. 242-253). Elsevier.
Moseley, R. L., Druce, T., & Turner-Cobb, J. M. (2020). ‘When my autism broke’: A qualitative study spotlighting autistic voices on menopause. Autism, 24(6), 1423-1437.
Moseley, R. L., Druce, T., & Turner‐Cobb, J. M. (2021). Autism research is ‘all about the blokes and the kids’: Autistic women breaking the silence on menopause. British Journal of Health Psychology, 26(3), 709-726.
Namazi, M., Sadeghi, R., & Behboodi Moghadam, Z. (2019). Social determinants of health in menopause: an integrative review. International journal of women’s health, 637-647.
Ohayon, M. M. (2006). Severe hot flashes are associated with chronic insomnia. Archives of internal medicine, 166(12), 1262-1268.
O’Reilly, K., McDermid, F., McInnes, S., & Peters, K. (2023). An exploration of women’s knowledge and experience of perimenopause and menopause: An integrative literature review. Journal of clinical nursing, 32(15-16), 4528-4540.
Pinkerton, J. V., Stovall, D. W., & Kightlinger, R. S. (2009). Advances in the treatment of menopausal symptoms. Women’s Health, 5(4), 361-384.
Pinkerton, J. V., & Stovall, D. W. (2010). Bazedoxifene when paired with conjugated estrogens is a new paradigm for treatment of postmenopausal women. Expert opinion on investigational drugs, 19(12), 1613-1621.
Polo-Kantola, P. (2011). Sleep problems in midlife and beyond. Maturitas, 68(3), 224-232.
Roth, T., Coulouvrat, C., Hajak, G., Lakoma, M. D., Sampson, N. A., Shahly, V., … & Kessler, R. C. (2011). Prevalence and perceived health associated with insomnia based on DSM-IV-TR; international statistical classification of diseases and related health problems, tenth revision; and research diagnostic criteria/international classification of sleep disorders, criteria: results from the America insomnia survey. Biological psychiatry, 69(6), 592-600.
Santen, R. J., Stuenkel, C. A., Burger, H. G., & Manson, J. E. (2014). Competency in menopause management: whither goest the internist?. Journal of women’s health, 23(4), 281-285.
Santoro, N. (2016). Perimenopause: from research to practice. Journal of women’s health, 25(4), 332-339.
Williams, R. E., Kalilani, L., DiBenedetti, D. B., Zhou, X., Fehnel, S. E., & Clark, R. V. (2007). Healthcare seeking and treatment for menopausal symptoms in the United States. Maturitas, 58(4), 348-358.
Wood, K., McCarthy, S., Pitt, H., Randle, M., & Thomas, S. L. (2025). Women’s experiences and expectations during the menopause transition: a systematic qualitative narrative review. Health Promotion International, 40(1), daaf005.
Zhu, C., Thomas, N., Arunogiri, S., & Gurvich, C. (2022). Systematic review and narrative synthesis of cognition in perimenopause: The role of risk factors and menopausal symptoms. Maturitas, 164, 76-86.
References for Behavioral Perspectives on Topics in Hormones and Behavior:
Altundağ, S., & Çalbayram, N. Ç. (2016). Teaching menstrual care skills to intellectually disabled female students. Journal of clinical nursing, 25(13-14), 1962-1968.
Ballan, M. S., & Freyer, M. B. (2017). Autism spectrum disorder, adolescence, and sexuality education: Suggested interventions for mental health professionals. Sexuality and Disability, 35, 261-273.
Barrett, R.P. Atypical behavior: Self-injury and pica. In Developmental-Behavioral Pediatrics: Evidence and Practice; Wolraich, M.L., Drotar, D.D., Dworkin, P.H., Perrin, E.C., Eds.; C.V. Mosby Co.: St. Louis, MO, USA, 2008; pp. 871–885.
Carr, E. G., Smith, C. E., Giacin, T. A., Whelan, B. M., & Pancari, J. (2003). Menstrual discomfort as a biological setting event for severe problem behavior: Assessment and intervention. American Journal on Mental Retardation, 108(2), 117-133.
Edelson, S. M. (2022). Understanding challenging behaviors in autism spectrum disorder: A multi-component, interdisciplinary model. Journal of personalized medicine, 12(7), 1127.
Gomez, M. T., Carlson, G. M., & Van Dooren, K. (2012). Practical approaches to supporting young women with intellectual disabilities and high support needs with their menstruation. Health Care for Women International, 33(8), 678-694.
Holmes, L. G., Himle, M. B., & Strassberg, D. S. (2016). Parental sexuality-related concerns for adolescents with autism spectrum disorders and average or above IQ. Research in Autism Spectrum Disorders, 21, 84-93.
Jain, N. (2024). Effect of hormonal Imbalance on mental health among young women.
Klett, L. S., & Turan, Y. (2012). Generalized effects of social stories with task analysis for teaching menstrual care to three young girls with autism. Sexuality and Disability, 30, 319-336.
Laverty, C., Oliver, C., Moss, J., Nelson, L., & Richards, C. (2020). Persistence and predictors of self-injurious behaviour in autism: a ten-year prospective cohort study. Molecular autism, 11, 1-17.
Mattson, J. M. G., Roth, M., & Sevlever, M. (2016). Personal hygiene. Behavioral health promotion and intervention in intellectual and developmental disabilities, 43-72.
Moreno, J. V. (2023). Behavioral Skills Training for Parent Implementation of a Menstrual Hygiene Task Analysis. The Chicago School of Professional Psychology.
Rajaraman, A., & Hanley, G. P. (2021). Mand compliance as a contingency controlling problem behavior: A systematic review. Journal of Applied Behavior Analysis, 54(1), 103-121.
Richman, G. S., Reiss, M. L., Bauman, K. E., & Bailey, J. S. (1984). Teaching menstrual care to mentally retarded women: Acquisition, generalization, and maintenance. Journal of Applied Behavior Analysis, 17(4), 441-451.
Rodgers, J., & Lipscombe, J. O. (2005). The nature and extent of help given to women with intellectual disabilities to manage menstruation. Journal of Intellectual and Developmental Disability, 30(1), 45-52.
Shors, T. J., Lewczyk, C., Pacynski, M., Mathew, P. R., & Pickett, J. (1998). Stages of estrous mediate the stress-induced impairment of associative learning in the female rat. Neuroreport, 9(3), 419-423.
Wegerer, M., Kerschbaum, H., Blechert, J., & Wilhelm, F. H. (2014). Low levels of estradiol are associated with elevated conditioned responding during fear extinction and with intrusive memories in daily life. Neurobiology of learning and memory, 116, 145-154.
Veazey, S. E., Valentino, A. L., Low, A. I., McElroy, A. R., & LeBlanc, L. A. (2016). Teaching feminine hygiene skills to young females with autism spectrum disorder and intellectual disability. Behavior analysis in practice, 9(2), 184-189.
References for Conclusions (Menstruation as a Vital Sign; Insulin Resistance and Hormones; Premenstrual Exacerbation)
Akturk, M., Toruner, F., Aslan, S., Altinova, A. E., Cakir, N., Elbeg, S., & Arslan, M. (2013). Circulating insulin and leptin in women with and without premenstrual disphoric disorder in the menstrual cycle. Gynecological Endocrinology, 29(5), 465-469.
Diamanti-Kandarakis, E., & Christakou, C. D. (2009). Insulin resistance in PCOS. Diagnosis and management of polycystic ovary syndrome, 35-61.
Eckstrand, K. L., Mummareddy, N., Kang, H., Cowan, R., Zhou, M., Zald, D., … & Avison, M. J. (2017). An insulin resistance associated neural correlate of impulsivity in type 2 diabetes mellitus. PLoS One, 12(12), e0189113.
Kolu, T. C. (2023). Providing buffers, solving barriers: Value-driven policies and actions that protect clients today and increase the chances of thriving tomorrow. Behavior Analysis in Practice, 1-20.
Kuehner, C., & Nayman, S. (2021). Premenstrual exacerbations of mood disorders: findings and knowledge gaps. Current psychiatry reports, 23, 1-11.
Lin, J., Nunez, C., Susser, L., & Gershengoren, L. (2024). Understanding premenstrual exacerbation: navigating the intersection of the menstrual cycle and psychiatric illnesses. Frontiers in Psychiatry, 15, 1410813.
Sullivan, M., Fernandez-Aranda, F., Camacho-Barcia, L., Harkin, A., Macrì, S., Mora-Maltas, B., … & Glennon, J. C. (2023). Insulin and disorders of behavioural flexibility. Neuroscience & biobehavioral reviews, 150, 105169.
Ueno, A., Yoshida, T., Yamamoto, Y., & Hayashi, K. (2022). Successful control of menstrual cycle‐related exacerbation of inflammatory arthritis with GnRH agonist with add‐back therapy in a patient with rheumatoid arthritis. Journal of Obstetrics and Gynaecology Research, 48(7), 2005-2009.
Vollmar, A. K. R., Mahalingaiah, S., & Jukic, A. M. (2024). The Menstrual Cycle as a Vital Sign: a comprehensive review. F&S Reviews, 100081.
Yu, W., Zhou, G., Fan, B., Gao, C., Li, C., Wei, M., … & Zhang, T. (2022). Temporal sequence of blood lipids and insulin resistance in perimenopausal women: the study of women’s health across the nation. BMJ Open Diabetes Research & Care, 10(2).
Cusp Emergence 