Tag Archives: ethics

New 4h course: Autism, TIBA and Ethics

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Posted by in Autism, BACB CEU, Behavior Analysis, behavior cusp, CEU, collaboration, continuing education, contraindicated procedures, Cusp Emergence University, CuspEmergenceUniversity, ethics, Fetal Alcohol Spectrum Disorders, Uncategorized

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Last time I wrote, I shared some ideas about this intersection. Today, the new course is up! Before you go check it out (and claim your February 2022 coupon for 20% off by typing ASD2022)– during the introductory month of the course)- learn why I’m so passionate about screening for trauma in a population so many behavior analysts have been working with (for some, virtually their entire professional lives).

Have you ever worked with someone in pain? How do we know if they’re currently hurting, whether it’s because they are sick, it’s related to interventions we chose, or from experiences we reminded them of? How would we know if that was the case? Did that person cower, freeze, or grimace? Did they flinch, close their eyes, seem to “zone out”? Perhaps someone has run away, played repetitively with the toys they had, or fallen asleep at school? Sometimes, respondent behaviors may be giveaways that people are experiencing fear or in pain, but successful avoidance behavior can hide that pain. Other times people have been through experiences making them more likely to use aggression or property destruction. In the least, we should consider whether our interventions cause harm. This harm could include causing our clients distress or pain, exposing someone to additional risks, detracting from their quality of life, failing to program in sustainable ways that transfer to the maintaining environment, and so much more.

A new training is up on Cusp.University on the intersection of autism, trauma informed behavior analysis, and ethics. By the time we near the end, we have discussed and revisited the idea of contra-indicated procedures. Given that lists exist for diagnoses of autism alone, why isn’t there a list of best practices appropriate for clientele meeting diagnostic criteria for autism who also come to therapy with trauma histories? Why is it so difficult to find articles suggesting best treatment paths for individuals with both autism and trauma related experiences in the literature? In behavior analysis, answers to these questions may be related to our field, its historical publishing practices, and the ethical and pragmatic need to individualize procedures for each client.

In terms of publishing practices, a panelist in ABAI’s “Exploring Publication Bias in Behavior Analytic Research” (which included Galizio, Travers, and Ringdahl, 2021) stated,

“No intervention is guaranteed to work for every individual, every time, in every context.”

They suggested that authors writing about their research should include more detailed descriptions of the conditions under which successful implementation of the intervention occurred.

When we screen for trauma related or aversive historical situations and stimuli, we often learn things that

  • help us prioritize treatment,
  • document risks for certain procedures,
  • avoid or prioritize certain stimuli,
  • detect environmental conditions that are acting as motivational operations and conditioned MOs,
  • and ultimately, perhaps minimize harm to our client.

Screening for trauma can help to identify individuals with prior risk factors who are at risk for experiencing additional adverse events and aversive conditioning. Attendees learn in chapter 1 some facts about how being autistic is to be at increased risk for trauma, bullying, abuse, increased likelihood of experiencing foster care—and in chapter 3, learn about the higher rates of experiencing restraint, seclusion and being excluded from school.

But another effect of screening – one that should affect all behavior analysts—could be an increased awareness of the fact that behavior analytic procedures are being used all the time for this population at the intersection of autism and trauma. Perhaps the least we can do is to begin doing behavior analysis with people instead of to people, and to be transparent, inviting, and open in looking at options—and their likelihood of causing harm either now in the future.

Let’s look at this juxtaposition: we have a great ethical responsibility to do no harm, but also an ability to cause great harm. With using any behavioral procedure there comes a risk that we may do just that. This is especially true when we don’t have literature evidence that a given intervention is appropriate and effective for the person’s needs given their history and current situation. Perhaps they don’t actually need behavior analysis seeking to change their behavior as much as they need a roof, a meal, a bus pass, a blender, a respite provider, a ride to the doctor, a coat, a medication, a trip to the dentist… the list could go on and on. So clearly the first step is to see what the person needs.

When designing an individualized behavior support plan, two things are important to consider:

(1) the risks and benefits for the client themselves, given their needs, values, environment, etc., (e.g., the long- and short-term outcomes of procedures and decisions, and

(2) evidence the procedure is appropriate for our client.

In terms of evidence, when considering decisions in context of the literature, few studies provide sufficient detail in characteristics of the participants. So it is difficult to tell, reminds the panel, which characteristics were present for study participants received successful or unsuccessful interventions. Thus we can’t really tell how many of the massive number of papers on treating behaviors in autism, also apply and were conducted with individuals with autism who also had a trauma background. But statistics suggest many of them must have. In the science of behavior analysis, each subject’s behavior is its own control, so if we control our conditions and try to measure well, we may reveal additional elements of historical and current behavioral environments that exert contextual and stimulus control on the client’s behavior- and that change their needs. At times, historical aversive conditioning experiences may have contributed changes making it painful or inappropriate for clients to experience certain interventions. As we discuss in the new training, some of those conditioning experiences may even have occurred during and as part of behavioral treatment.

We can’t know for sure what our clients have been through. But when owe it to them to honor those experiences if they are comfortable sharing them.

Here are some of the things you’ll learn.

Course Objectives: 

1. List connections between autism and trauma in the research 

2. State different kinds or examples of trauma that may affect individuals with autism 

3. State supportive ways to ask about trauma histories

4. Select examples of how medical history can be related to trauma

5. State examples of repertoires beneficial for practitioners who serve clients affected by both autism and trauma

Ready to learn more? The new training offers hints from Dr. Kolu on how we begin the conversation about informed consent and screening for trauma, why assent is so important, how trauma and autism might intersect with medical needs affecting our clients, and more. And all the resources are available as free content in the preview section, so go grab that now! See you at a conference soon or find us online. And thank you for listening!

Homebound and Vulnerable: What will you do to prevent abuse and neglect?

24 Tuesday Mar 2020

Posted by in adults, Autism, Behavior Analysis, boundaries of competence, children, Community, coronavirus, Covid-19, Early Intervention, Education, Education and Trauma-Informed Behavior Analysis, ethics, mental health, Uncategorized

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This is the 19th article in a series on Trauma-Informed Behavior Analysis by Dr. Camille Kolu, BCBA-D. Start by becoming informed; then please read to the end if you’re interested in taking steps with your organization to support therapists and teachers to continue to fulfill their roles as mandatory reporters.

Child abuse, elder abuse, domestic violence, and abuse of people with intellectual disabilities is going on all around you. It may have just become simultaneously more prevalent, invisible, and insidious.

For example, in some areas, there has been a marked decrease in calls to the hotlines that typically lead to welfare checks for vulnerable people in their homes to insure that families have resources they need, children are not being abused or neglected, and appropriate actions can be taken if they are. (See this story from Colorado reporting a drop in calls the 9th and 10th of March as schools began to close).

Across the nation, different states are reporting similar decreases in calls but also a spike in the number of serious child abuse hospitalizations and even deaths.

Reasons for this disturbing increase are numerous. Little annoyances become big ones when there is no possibility of a break and both mental health (e.g., patience) and physical (e.g., food and sleep) resources are running thin. Even a normal battle on whether your kid will eat the peanut butter sandwich becomes a crisis when you’re trying to feed several people a balanced diet with whatever dwindling foodstuff you still have in the cabinet, while money (and outside trips) become scarce.

For many families, the struggle is not only real but getting uglier by the day, by each hour the kids are home from school.

There is conflicting advice, some of it really unhelpful, yet most of it well-intentioned. (I read a recent article about how we should just give in and let kids watch endless videos during this unprecedented time; but for many children, a huge increase in access to media may be accompanied by major behavior challenges (and even injurious and aggressive behavior) when parents try to have them turn it off for meals or bed. Research shows increased screen time can cause impulsivity, hyperactivity, and inattentiveness,

all of which are even more difficult to deal with when you’re cooped up. Of course, you need solutions, and the quick fix is even more appealing right now.

And there are major barriers to resources. Some have said this crisis is leveling the playing field, but really, it’s revealing discrepancies.  

Being quarantined at home doesn’t hurt that much when there’s plenty of food, you already know how to navigate technology to work from a home office, and there is room and time to get away from housemates or family members for a little while.

Being at home with other people who normally require 7 to 9 hours of behavior support and school-provided structure, let alone meals, while you work to make ends meet—that is another story altogether.

So there are the struggles to which we can all relate, and then there is the reality of jumping into these struggles with no help, no end in sight: There is the reality of suddenly not being able to be by oneself for even a minute, and not knowing when it will end; there are children whining or crying (or hurting themselves while other things need their caregiver’s attention; there is behavior, so much behavior, that a parent doesn’t know how to handle and is made worse by a lack of structure, suddenly upended routines, and for some, the complete loss of safety figures.  At the same time, there are abusive people who are now alone with their victims for the next few weeks.

Maintaining a safe environment for a child depends on several behavioral and environmental factors. Right now, those factors are not all present. Instead, we have

-Caregiver behaviors that are really important to keep people safe, but may not be FLUENT (such as giving effective instructions to a child, creating a schedule for several people, or responding to unsafe behavior that you usually don’t have to respond to)

-Caregivers that may physically present, but not AVAILABLE (e.g., an adult who can provide continuous, adequate supervision to every single member of the household who needs it)

-The presence of new circumstances creating unsafe environments (such as having 3 children with special needs home at the same time, for hours and days on end, and without the things (therapies, bus drivers, respite workers, social outings and educational time) that typically provide structure and relief)

-The additional presence of huge stressors (the unending flow of news about the virus; the dwindling of food and resources; the loss of jobs)

-Competing, sometimes incompatible, needs (like people home from work who need quiet to make money but who also have to provide constant caregiving and supervision; or people who have intellectual and other disabilities and are without their scheduled programs, events, therapies, social opportunities)  

-Therapists and teachers who are working from home or not at all, but who normally document and relay evidence that a child or adult may be being abused, mistreated or neglected

These factors and more combine to produce

-The occasion for more abuse or neglect to occur

-Decreased opportunities for abuse to be reported

-Emotional and physical needs that may make the outcomes of a child being quiet or following directions suddenly much more important or reinforcing, whatever the cost

So, my therapist, day program provider, and educational staff friends- how will you add and document safety checks for all your clients on a reliable schedule to take the place of “having eyes on” the client in your clinic, their home, or your school or program?

There are no hard and fast answers. For instance, some behavior analysts are out of work; could they be repurposed to providing online support of families with children at home? Having eyes on the family is good, but it’s also introducing a risk that we will give advice that we don’t have an assessment to back up, or that is not fully safe to implement. And while I’d like to share ideas for behavior analysts to incorporate safety checks of your clients virtually, it’s most important for me to encourage you to reach out, right now, to your organization—and ask for your TEAM’S plan to do that. This is because different states and areas have different guidelines and requirements for you to follow depending on your local recommendations for HOW you monitor and report unsafe situations. You need to do it, but you should follow your local guidelines and state laws.

  1. Recommit to your role as a mandatory reporter for individuals with disabilities, the elderly, or children, if you are a therapist, teacher, etc.
  2. ACT as an employee: If you work for an organization, act by asking your company what their contingency plan is for all employees to fulfill this role given our emergency situation, and how you can help.
  3. ACT as an employer: If you own or lead an organization, stop right now and generate a brief plan for how you’ll support your team to fulfill their roles as mandatory reporters. Here are some ideas:
    • Write up a plan and email it out. Bonus points if you schedule an online meeting right away to disseminate it and give examples and encouragement.
    • Assign everyone a recommended frequency to make check-ins that specifically deal with the client’s physical well-being and mental health.
    • Give the team an example for what questions they can ask, and what they should avoid (if needed) to maintain everyone’s safety in the home they are looking at.
    • Tell employees to document the outcome of their checks (e.g., if they notice things that typically would indicate possible abuse or neglect; or if they notice something might be wrong that warrants another check-in from a supervisor on your team; if calls are made to CPS or APS)
    • Reinforce and encourage the behavior of employees who follow the plan, including having social support carved out for them so they don’t have to go it alone.

Telehealth provision is already a new skillset for some employees, including teachers, and if they are suddenly without any social support when they used to be able to walk down the hall to the counselor, administrator or psychologist on site, they may freeze and wait when action is important. It’s your job to make the unfamiliar but correct action as easy and supported as possible.

And here’s a notice: Social services haven’t closed down. In Colorado, not only are they still making visits, they are hiring. Hotlines are available and staffed with trained professionals to take your call.

Resources: Read guidance from the Behavior Analysis Certification Board on ethics, safety and more related to Covid-19.

Here’s more on how a few states are monitoring this issue.

Colorado:

Call 1-844-CO-4-KIDS if you suspect abuse or neglect

https://www.coloradocac.org/

For birth to 3 receiving services: http://coloradoofficeofearlychildhood.force.com/eicolorado/EI_QuickLinks?p=Home&s=EI-CO-Response-to-COVID-19&lang=en

Ohio: https://www.cleveland.com/court-justice/2020/03/staying-at-home-amid-the-global-coronavirus-pandemic-creates-new-dangers-for-victims-of-domestic-violence-and-abuse-experts-say.html

And in Texas, use this info:

https://www.allianceforchildren.org/

If you suspect a child is being abused or neglected, please contact the Texas Department of Family and Protective Services toll free at 1-800-252-5400, 24 hours a day, 7 days a week.

You may also file a report using the secure TDFPS website. Reports made through this website take up to 24 hours to process.

The Texas Abuse Hotline is 1-800-252-5400.

Seeing Snakes and Spiders

27 Friday Sep 2019

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

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

spider

What did you do when you saw this picture? Chances are you experienced some additional events beyond just “seeing it”. Did you jump? Experience an increase in your breathing rate? Use some choice verbal behavior? Avert your eyes? (And are you prepared to read on? Fair warning… there’s a snake coming up).

Seeing with fresh eyes

I noticed a couple of things about our culture, and fear responses, this past week.

My young daughter’s love for flap books—the kind where you pull back a piece of paper to reveal something—knows no bounds. So she was instantly drawn to a tattered old library copy (apparently she shares this love with lots of peers) of “Buzz Buzz, Baby”- with poorly rendered babies exploring “bugs”. Around the third page the baby pulls back a web flap to unveil, in the book’s words, “EEK! The itsy bitsy spider!”

Whenever I read the book to her I leave out the “Eek!”.

I think she can come up with that on her own, if she happens to, although chances are she’ll get it from me in a non-mindful moment. (In the 1980’s Cook and Mineka did a classic study in which infant monkeys “acquired” a persistent fear of snakes by watching their scared mothers encounter a snake).

Now that we’ve moved out to the country, we encounter our own “Itsy” (and many for whom that name is woefully inadequate) all the time. (I do recommend this thing called the BugZooka… it does work really well, if you like catch-and-release). Itsy and I go way back, and not necessarily in a good way, although I always appreciate her beauty. But I still want to be warned before you text me her picture, dad.

This summer, one tenacious spider (pictured, top) built a web, over and over, in a windy area outside the kitchen, where we see it numerous times daily. The first few (ok, few hundred) times I nearly jumped out of my skin. When I remembered in time, I was very careful to breathe and compose myself before walking to the sink with my daughter, where I’d point out the spider cheerfully and sing (with all the hand movements) the requisite song. Before long she was signing the song herself. Next I noticed myself no longer jumping when I saw the spider.

THEN… one windy morning Itsy was gone. Gone!

I didn’t breathe a sigh of relief.

I was surprised and curious to feel a strange emotion… like MISSING. I missed her! Was she alright? Would she come back? (She was. She did).

With painful awareness that this is temporary, I often marvel that my daughter’s eyes are not only young… they are unconditioned. They don’t have a lot of pairings with events like scary movies about this deep primate fear, being bitten, or seeing spiders while a parent jumps and screams. They are fresh, curious, hopeful eyes.

Yesterday we chanced upon something rather larger than even the biggest spider. It was this old girl… fat and long, with ring upon ring adorning her useful brown rattle. Depending on my readers, maybe you’ll be happy that instead of grabbing a hoe, I called a guy I read about in my new community’s online forum… apparently this guy LOVES snakes. “ANY snake’s worth my time”, he told me as he jumped in his truck. 35 minutes later he had driven up to our homestead, hooked it and taken it. Now it’s in a quite different rattlesnake heaven than the kind I had sort of planned to send it… blissing out in a protected wilderness area up near Fort Collins, I’m told.

rattler

As he removed our snake into a large vented box and curiously counted the rings (while remarking on how huge it was), the guy’s face was composed; he exuded a strange calm excitement. Normally, the fear response to snakes and spiders is part of our biology. Evolutionary biology has several theories why it’s present even in infancy, and why it might have behooved our ancestral mothers to experience more arousal and get out of there to protect their young in the presence of these critters. I can’t help but wonder what this guy’s history is like. Why does he love something that most of us are scared of?

Kids with traumatic histories

If you’re an educator going back to school, many of your kids are coming in with an avoidance response, or a “get out of there!” escape response, ready to go. Some of them will use these responses in the most annoying ways, dropping all their work on the floor or crawling under desks when you announce the quiz. But some of them have a special background you can’t see. For some, they will use these “fear responses” when they encounter “triggers” that you and I do not think of as scary.

Why is that?

Well, the things that were there when they experienced really bad situations are now “paired”, living together in their past, the same way I smelled an old lady yesterday wearing my own granny’s soap and got emotional thinking about my dear departed loved ones. Or the same way you hear a certain song from your high school dance and think about that year, or that person, or that kiss.

And that’s not all. Psychology explains in anxiety journals why, if you’re a person with an intense “fear” or phobia of spiders, not only do you spot them more quickly and tend to see them where your peers might see other things, like mushrooms or flowers faster in the SAME PICTURE—but to you, they also appear BIGGER.

What can we do about it?

How can we help students show up for their education and get all the learning opportunities they can… even when the school, teachers, and peers accidentally give them “fear related” stimuli all day long? (While psychology explains partly WHY these pairings happen, behavior analysis does too, especially if you read some relational frame theory, learn about respondent conditioning, and take a long-term functional analytic approach. Behavior analysis also goes a long way in helping the helpers undo some of the damage, teaching kids to approach adults and “unpair” adult attention from it’s previously bad parts: if I’m a student who has been through neglect abuse, my teacher coming over to me to praise my “good behavior” might not be a welcome stimulus at first… and my teacher’s praise, as well-intentioned as it may be, might not work).

Cusp Emergence University has been hard at work getting the new online training course ready for educators, and behavior analysts who work in education. We hope to help you to start answering these questions for yourself and your students and teams. On Monday, September 30, our course “Education and Trauma-Informed Behavior Analysis” opens to a 7 day sale (use the code EDTIBA10 for 10 percent off this CEU opportunity). We’re providing BCBA’s and BCBA-D’s with 3.5 continuing education credits, and 3 of those are in ethics.

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Sign up now!

CEU stands for Cusp Emergence University!

13 Tuesday Nov 2018

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

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

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

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

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

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

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

Too risky to document risks?

17 Tuesday Jul 2018

Posted by in adults, Behavior Analysis, behavior cusp, Behavioral Cusp, boundaries of competence, collaboration, Community, Education, ethics, resources, risk analysis, risk assessment, risk versus benefit analysis, supervision, teaching behavior analysis, teaching ethics, trauma, trauma-informed behavior analysis, Uncategorized

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This post is part of a series on trauma-informed behavior analysis by Dr. Camille Kolu, Ph.D., BCBA-D.

When treating behavior concerns after trauma, we may find that clients exhibit risks to themselves, risks to their community, and risks to caregivers that should be documented. Why have behavior analysts sometimes turned a blind eye to documenting these risks? Read on to discover some common reasons I found in the field, and ways we can address them. 

When it’s too risky to even consider the risks

Our field has adopted a Compliance Code which mentions the need to document risks. As an instructor for courses in a BACB-approved course behavior analysis course sequence, I use a textbook that provides sample templates for documenting and analyzing risks. And as a practitioner, I have found that my analysis or assessment of risk is almost always helpful to a case (as in some situations I’ll describe below), not to mention that it’s quick and simple it is to do.

Despite these facts, most behavior analysts I encounter do not analyze risks in any sort of written format. The behavior analysts around me range from BCBA-Ds to RBTs, and many have expertise and long careers. Why are we averse to documenting risks?

I have been researching the answer to this question for several years, and often the answer is “because I don’t have a good risk assessment”. So I made some and piloted them with different agencies, working through the problems of how to identify, define, document and mitigate the risks related to the populations with whom I work most closely. But at a recent training opportunity I received a different kind of answer, and I think it’s too important to keep to myself.

Some of the BCBA’s I talked to at that event were not documenting risks, they acknowledged, because it was just too risky.

At first it seemed counterintuitive. If I was providing a new document that made it easy to document several options, and the potential risks and benefits of each, wasn’t that inherently reducing the risk? No, it turns out. To many of us, highlighting a risk necessarily imposes some degree of liability.

We’ve faced this challenge before. In pointing out a problem we may become partially responsible for solving it, as some educators have learned the hard way when their schools are upset with them for discussing the observations of a student’s difficulties outside of the official process. This responsibility may carry a financial burden or create an unsolvable problem in a resource-poor area. And some pediatricians I know have mentioned the frustrating dilemma of being given a new depression screen for teens or moms, only to have nowhere to go with the results.

A new ethical responsibility is only as useful as your agency’s process to fulfill that responsibility, and procedures to support the people implementing the new responsibilities.

And in the discussion with the BCBA’s that day about risk documentation, I learned something really interesting. The specific language I used made a huge difference in their willingness of adopting a new procedure.

When I called it a “risk assessment”, BCBA’s were unwilling to adopt my new “assessment”, even if it was backed up by the compliance code and plenty of evidence and anecdotes how it has supported my work.

But when I called it a “risk versus benefit analysis”, they were willing to try.

The difference?

“Risk assessment” is a loaded term that carries legal weight in many contexts.

On the contrary, the other term (“risk versus benefit analysis”) is something that I use daily, and that is simply a process of documenting and analyzing the several different options available, together with their respective potential risks and benefits. It’s called for by the Compliance Code (and discussed by Bailey and Burch in their Ethics text).

According to the Compliance Code, “a risk-benefit analysis is a deliberate evaluation of the potential risks (e.g., limitations, side effects, costs) and benefits (e.g., treatment outcomes, efficiency, savings) associated with a given intervention. A risk-benefit analysis should conclude with a course of action associated with greater benefits than risks.”

The Compliance Code mentions risks in several places. In 2.04b, we are to consider risks of performing conflicting roles (e.g., when we are clarifying third party involvement in services). In 2.09c we are asked to use a risk-benefit analysis as part of our process in deciding between different treatments. And in 4.05, we are asked to work with stakeholders to present the potential risks versus benefits of which procedures we plan to use to implement program objectives. 7.02 asks us to consider risks involved, when there may have been an ethical or legal violation by a peer. And of course, we consider the potential risks and benefits when doing research (9.02).

The Task List does not mention “risk” by name, but alludes to the process when requiring that we are required to be able to state and plan for the possible unwanted effects of reinforcement (C-01), punishment (C-02), or extinction (C-03), as well as behavioral contrast (E-07). Similarly, the Code makes it clear that we are to identify potential for harm with using reinforcement (4.10) and identify obstacles to implementing recommended treatment (4.07).

In my practice, the most efficient way to meet all these objectives and more, is to complete a risk-benefit analysis. I love to include sections on mitigating the risks I do identify, so that the team can make an informed decision about what resources, training, information or support they will need to implement the least risky option.

And a final benefit I’ve heard many stakeholders mention during this process (and typically I do the analysis as an open discussion in which they are involved and brainstorming), is usually stated like this: “I didn’t think we had any other options, but when we approached this with a goal to identify alternatives and the risks and benefits of each, we uncovered several more”.

The risk versus benefit analysis is something I document, add to a treatment plan or employee or client file or IEP, or simply something I share with the team in writing and in person to solidify systems support for my next move. Recently, the following situations were ameliorated by using a transparent risk versus benefit analysis. Outcomes included increasing appropriate funding; securing appropriate medications; identifying appropriate caregivers; funding appropriate training; and improving client satisfaction.

-what kind of residential facility would be most appropriate to move a client to

-whether to discharge a client now or later

-whether to use a cheaper program with fewer resources or a costly one with many

-whether to put a client in a foster home in a potentially risky but supportive situation

-whether to delay an assessment to have an operation

-under what conditions should we discontinue a client who violates our informal no-show policy

-what caregiver to select from several available

-how to appropriately include police contact in a plan in a way that reduced long term risks

-what medication to decrease and when

-whether to put a student in a restrictive school with more behavior support, or a less restrictive placement with more social interaction options

As you can see by the last two, sometimes these decisions are not cut and dry. They depend on the team and family input, and one family may weigh a given outcome more heavily than another.  Everyone has a history. To do these analyses in a compassionate and open way is important, and sometimes we don’t agree. To involve high level stakeholders and funders is critical as well.

What are the risks of doing a risk-benefit analysis? Perhaps you’ll highlight more risks than you thought were there; perhaps you’ll have to take some responsibility for the outcome of your recommendations. But what are the risks of avoiding this important process? If you are certified, your responsibility as a behavior analyst “is to all parties affected by behavior-analytic services” (e.g., 2.02). So are there risks of not documenting risks? Sure. You could cause harm or be negligent if there is a known risk you didn’t plan for or discuss with the team. Just like there are risks, there are benefits too. Doing a good risk versus benefit analysis is certainly a helpful cusp for supervisors and behavior analysis leaders to acquire! Many times we have uncovered risks that can be totally avoided next time if we were to act now to change or solidify policies, or use preventative measures in the future. A risk-benefit analysis can be a wonderful contribution to discussing lessons learned.

There are more options to be uncovered. Go out there and find and document them!

Want a resource? Check out the 3rd edition of the Bailey and Burch text Ethics for Behavior Analysts (2016), read more on Cusp Emergence , or check out a risk versus benefit tool (I like to do this on a whiteboard with my teams).

Convinced? Have a question? Drop us an email. And thanks for reading about this important topic. We’d love to see how YOU document and discuss risks!

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

26 Monday Feb 2018

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

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

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

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

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

Part 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 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.