In this story about small town stranger appreciation, a mom learns lessons while her little kid grows up a little more, making kind decisions about safety, cats, and personal capabilities. Let’s nurture our relationships and read on. To begin, why is this balloon in the bathtub?
Short answer: to protect our cat (Rolo, who can open every door except a shower door) from GI distress caused by eating the string.
Long answer: My 4-year old son is building resilience, self-discipline, confidence, and communication skills. Today, he acquired a balloon from a Habitat for Humanity kiosk at the local Berthoud farmer’s market (which makes up for its well-known lack of vegetables by being located at the new splash pad park, bringing multiple sourdough purveyors, and hosting the beloved Wildfire Arts kids art table. Today there were even dancing local ladies and a massive drum circle. And it’s really not the town’s fault about the veggies. We have a notoriously short growing season, etc etc).
My kids love balloons. Yes, I know they’re dangerous… a family I know had a child fall from a large mylar one at his own party and get seriously injured. In our family we aren’t allowed to put them up to our mouths, and so on. Mine play with them a few times a year under supervision…. STRONG supervision. This is partly because we have a large cat who loves to eat that curly, delicious, devilish shreddable balloon string. He gets very sick from eating it, and he just can’t stop. If it’s in the house, he’s gonna find it and have it for his own.
So we got a balloon anyway. They were gleeful, knowing this was rare. The kids ran to the playground, clutching their strings. Enter some sort of spinning playground equipment and a spill. No scrapes, no blood, no bump… but snap! My son’s balloon was gone like that, soaring to the sky as if we’d meant to poison nature. I’m so sorry, birds. I really should have known.
Well, there was another family observing. I’m not going to say they caused the disaster, but they sure fixed it. (In truth, a park dad had been giving all the kids massive pushes on this spinning piece of park equipment, which led to riotous laughter and a moment for me to call my own father to check on him after some difficult health issues early this month). I saw the spill, the cut string, the loss all play out in slow motion and was ready when my 4 year old sprinted to me screaming as I slammed my finger down on the phone fast to spare my dad the screams in his phone ear. Are you hurt? “No.” Are you ok? “NO!”
That darn balloon. I went into triage mode. The kids were given some options from which to pick (stay here and play a little but we have to use nature friendly voices again; taste a pickle and calm down with mom; go home right away, etc). Kid opted for a pickle and kid 2 went on spinning, her balloon much more securely attached to her hat band. It’s a pink cowgirl hat and she is NOT taking that thing off. But her 4-year old brother was SO SAD.
You know those moments, parents? You know when you COULD go get another (whatever spilled-melted-dropped-broken-ruined) thing, but it’s a long way away, and isn’t there a lesson here crammed in there that you don’t want to miss and don’t want your kid to miss? (And what about the voice from your past reminding you that when you were a kid and that lady next to you at Disney broke your balloon with her 1980’s cigarette and she didn’t apologize and your parents did not buy you a new one and how will he learn a lesson if you don’t inflict on him the pain you felt when you were 6… just me? To be fair, I didn’t remember it. My dad reminded me about it later as I recounted the blue balloon story.)
“OK but mom, it was not his fault!” my brain argued. “He fell and the string broke and he. is. SO. SAD!”
Yet I stuck to my proverbial guns. I wasn’t mean, I was soft and sympathetic, walking with my crying kid back to the car as he suffered loudly and his sister bounced along with her balloon. And guess what happened before we left the parking lot? If you live in Berthoud maybe you already guessed.
The stranger family re-appeared. One of the kids was clutching a lollipop- Oh please don’t let my kids notice that, I prayed. Too late, my daughter instantly said the quiet part out loud. But that didn’t matter, because… the stranger-family-dad (sorry kind sir, this is what my children have dubbed you) was holding out a balloon. “He took a pretty big spill back there,” he said apologetically. “We decided we didn’t want him to have to leave without a balloon.”
Glory be! Is this the small town feeling creeping up my arms, a mix of chill bumps and gratefulness and humanity and embarrassment (my toddler was just about to leave without one and darn it I was going to make sure he was ok with that)?
We humbly and gratefully said big thank yous. My little guy’s eyes were dazzling blue worlds of gratitude staring up at this family, accepting his balloon. He clutched the string like I clutch his hand at Trail Ridge Road overlooks while we stare over the edge.
There were so many lessons today. First, the amazement of my son: “I didn’t realize a stranger would be so kind to another stranger!” Then, the detailed discussion of situations when it is ok, versus not ok, to take things from strangers. We discussed the role of my presence, of the dad asking me “can I give this to him?”, and other nuanced questions only a 4- and 6-year-old can generate. We rode home happy.
And now it was nap time. Here’s where his character development really comes into the story. “Mom,” he said sleepily, “I really, really love playing with the balloon. So I think we better work together to find a safe place that is not inside my room. Especially for Rolo. Can you help?”
Yes, son. I got your back on this one. He’s asleep now, napping after all the excitement, while the cat lies in wait outside the bathtub and I take in the wonder that is 4-year-olds growing up.
Oh… and I love other families as well. I provide mentoring to families, therapists and teams that gives them the tools to transcend trauma. See my courses at www.cuspemergenceuniversity.com, join a group with me, book an appointment, or just email me any time.
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).
Another article in the trauma-informed series by Dr. Teresa Camille Kolu, Ph.D., BCBA-D
In relationships we do rituals.
“BLECH!” Startled, I looked down at my sweet, expressive daughter with a true disgust face. Everybody laughed. I was kinda mortified but I laughed too. The woman at MeOhMyCoffeeAndPie (you HAVE to go) had just answered her question with “it’s sauteed onion” when my kid asked “what’s the scone flavor today?”
Ok, I guess she wasn’t expecting that.
I was too caught up noticing this awesome tiny, framed quote by the display case. As a young reader I LOVED Larry McMurtry, see, who wrote Lonesome Dove and a whole lot more. He and I both went to UNT (decades apart, of course) where he gave us a wonderful author meet and greet (early 90s for me, when this kid was not even a twinkle). The coffee and pie shop had quite appropriately chosen to frame this gem of a quote: “She made great biscuits, but her behavior was TERRIBLE”.
My daughter and I were out doing a ritual Saturday thing. My mom used to sing “Come Saturday Morning” with me (we had the sheet music, so it was right up there with “Country Roads” and “The City of New Orleans” in my book). And sometimes we would spend time just us, and I would look at her hands and sing this song in my head. Saturday mornings, for a couple precious hours, are time when my daughter doesn’t have to share me with her little brother, and she pays me back by asking me questions I can’t answer. It’s at this time I learn that even 5 year olds wonder things about God and the universe, have nightmares, they can have crushes, they have fears, they might still want to hold my hand.
I LOVE biscuits but I love her even more. I love her more than her behavior, even that sort of behavior that makes you want to fire the babysitter just so you’ll never have to greet that face that saw the terrible behavior you thought your kid would never do in public and after all, you are a behavior analyst! (Do I think it’s easier because I’m a behavior analyst, my new friend asked recently? Heck no. I personally think it’s harder. But I do think being a parent has made me a better behavior analyst.)
So in relationships we do rituals, like setting up meaningful goodbyes when we leave the room, or when rhythms change and we won’t be spending as much time together anymore. If not, we leave devastation.
When I watch animals grieving each other’s deaths… especially horses and dogs… I notice how fully present they are for the goodbye.
And I am always grieved to consider the implication: such a meaningless slog of goodbyes without reason, or participation, we inflect this on clients when caseloads shift; when a therapist moves; when a client with certain behaviors moves into Hall B, so we just HAVE to abruptly move Client A into Hall D, so they won’t antagonize each other and never mind Client A will never again see her best friend client, or even the janitor—who was like a mother to her and had been there for 12 of the client’s 15 years in this mental facility again.
We often have to make hard decisions, but we should ask questions (“what really hurt your feelings this past week? Today?”) because in relationships we apologize when we’re wrong.
When we realize we hurt others, we shift so that we won’t keep doing the hurtful thing.
My mom remembered the pain of being hurried as a child. I knew that, and I forgot it. I remembered it again this month when I was going through an exercise I was making for a new workshop we will offer at cuspemergenceuniversity.com. The exercise has us grownups go through questions that reveal the triggers for us – the things in our everyday situations that make us more likely to react swiftly (often in a hurtful way) to the others around us. And I realized two things: being hurried doesn’t feel good to children, and hurrying children doesn’t feel good to adults. So what do we do? This week, maybe you will notice a ritual that is always done with urgency, and think, how does this feel? What would this feel like if I slowed down? Now, the harder part: What would it take for me to build in space around this… ten extra minutes before it, so that we don’t have to experience this, every single time, in hurried mode? I tried this, and my children really love it, although I won’t hear about it from them. Their lingering hugs (mama, don’t let go first!) and their wonder as we have time to look around the yard for a new flower before we buckle our seatbelts… the absence of urgent reminders and exasperated sighs… perhaps even a reduction in tense moments when I’m about to lose it and yell. These changes are rewarding enough for me to keep doing this. Because I love them more than biscuits.
Yes, rapport is often transactional. Although it was by design at first, it doesn’t always have to be that way. I talk about this just a little bit in my buffers article, in the relationship section. And in the trauma sensitivity course we talk a little about how to be more sensitive to what folks go through (including your staff) so that YOU can be a little less harsh, a little more supportive, around things you didn’t even realize were hurting the other person.
In relationships, we apologize; we give freely; we do things uncontingently (yes, I know you won’t be able to look that up, and there’s a reason- we talk about it more on instagram and it bears more attention); and we are generous with things the person really needs, like time, kind words, and those little rituals that they consider special. Have you ever worked with a therapist the client really adored? Or a professor beloved by their students? I remember two. The professor is loved and really loves. She gives generously of her wisdom, time, and appreciation for students. (You wanted to ace her class and reflect what you admired in her, even as she whispered the things that made you more of yourself, more creative and passionate and able to grow confidently in the direction of your dreams.) The other person I remember is a therapist who had kids riding on her shoulder at recess in our mixed school for kids with developmental differences and peers. And those folks taught me that you can have instructional control when it’s time, and still have fun with the people who look up to you. Rapport IS often transactional. But the relationship doesn’t have to be.
Thanks for reading.
Oh… and I personally think, in the Longmont area, that Lucille’s has the best biscuits.
And OhMeOhMyCoffeeAndPie has the best lemon bars, if you’re wondering.
I love you more than biscuits, daughter of mine. And I love you even when your behavior is terrible.
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!”.
Now that we’ve moved out to the country, we encounter our own “Itsy” (and many for whom that name is woefully inadequate) all the time. (I do recommend this thing called the BugZooka… it does work really well, if you like catch-and-release). Itsy and I go way back, and not necessarily in a good way, although I always appreciate her beauty. But I still want to be warned before you text me her picture, dad.
This summer, one tenacious spider (pictured, top) built a web, over and over, in a windy area outside the kitchen, where we see it numerous times daily. The first few (ok, few hundred) times I nearly jumped out of my skin. When I remembered in time, I was very careful to breathe and compose myself before walking to the sink with my daughter, where I’d point out the spider cheerfully and sing (with all the hand movements) the requisite song. Before long she was signing the song herself. Next I noticed myself no longer jumping when I saw the spider.
THEN… one windy morning Itsy was gone. Gone!
I didn’t breathe a sigh of relief.
I was surprised and curious to feel a strange emotion… like MISSING. I missed her! Was she alright? Would she come back? (She was. She did).
With painful awareness that this is temporary, I often marvel that my daughter’s eyes are not only young… they are unconditioned. They don’t have a lot of pairings with events like scary movies about this deep primate fear, being bitten, or seeing spiders while a parent jumps and screams. They are fresh, curious, hopeful eyes.
Yesterday we chanced upon something rather larger than even the biggest spider. It was this old girl… fat and long, with ring upon ring adorning her useful brown rattle. Depending on my readers, maybe you’ll be happy that instead of grabbing a hoe, I called a guy I read about in my new community’s online forum… apparently this guy LOVES snakes. “ANY snake’s worth my time”, he told me as he jumped in his truck. 35 minutes later he had driven up to our homestead, hooked it and taken it. Now it’s in a quite different rattlesnake heaven than the kind I had sort of planned to send it… blissing out in a protected wilderness area up near Fort Collins, I’m told.
As he removed our snake into a large vented box and curiously counted the rings (while remarking on how huge it was), the guy’s face was composed; he exuded a strange calm excitement. Normally, the fear response to snakes and spiders is part of our biology. Evolutionary biology has several theories why it’s present even in infancy, and why it might have behooved our ancestral mothers to experience more arousal and get out of there to protect their young in the presence of these critters. I can’t help but wonder what this guy’s history is like. Why does he love something that most of us are scared of?
Kids with traumatic histories
If you’re an educator going back to school, many of your kids are coming in with an avoidance response, or a “get out of there!” escape response, ready to go. Some of them will use these responses in the most annoying ways, dropping all their work on the floor or crawling under desks when you announce the quiz. But some of them have a special background you can’t see. For some, they will use these “fear responses” when they encounter “triggers” that you and I do not think of as scary.
Why is that?
Well, the things that were there when they experienced really bad situations are now “paired”, living together in their past, the same way I smelled an old lady yesterday wearing my own granny’s soap and got emotional thinking about my dear departed loved ones. Or the same way you hear a certain song from your high school dance and think about that year, or that person, or that kiss.
And that’s not all. Psychology explains in anxiety journals why, if you’re a person with an intense “fear” or phobia of spiders, not only do you spot them more quickly and tend to see them where your peers might see other things, like mushrooms or flowers faster in the SAME PICTURE—but to you, they also appear BIGGER.
What can we do about it?
How can we help students show up for their education and get all the learning opportunities they can… even when the school, teachers, and peers accidentally give them “fear related” stimuli all day long? (While psychology explains partly WHY these pairings happen, behavior analysis does too, especially if you read some relational frame theory, learn about respondent conditioning, and take a long-term functional analytic approach. Behavior analysis also goes a long way in helping the helpers undo some of the damage, teaching kids to approach adults and “unpair” adult attention from it’s previously bad parts: if I’m a student who has been through neglect abuse, my teacher coming over to me to praise my “good behavior” might not be a welcome stimulus at first… and my teacher’s praise, as well-intentioned as it may be, might not work).
Cusp Emergence University has been hard at work getting the new online training course ready for educators, and behavior analysts who work in education. We hope to help you to start answering these questions for yourself and your students and teams. On Monday, September 30, our course “Education and Trauma-Informed Behavior Analysis” opens to a 7 day sale (use the code EDTIBA10 for 10 percent off this CEU opportunity). We’re providing BCBA’s and BCBA-D’s with 3.5 continuing education credits, and 3 of those are in ethics.
(Part 14 of a series of posts about Trauma-informed behavior analysis by Dr. Teresa Camille Kolu, Ph.D., BCBA-D)
Connections between mental health and behavior analysis
This topic is always close to my heart as I work regularly in mental institutions, and as my business supports wellness practices that affect everyone—including those of us who need help prioritizing our own mental health. But it’s an especially important topic right now: May is Mental Health Month!
Sometimes my work involves conducting an assessment to see whether a client needs behavior analysis, or mental health support, including ways to thrive with a history that includes mental illness. In other words, sometimes (many times!) directly providing mental health support goes beyond my scope, and my job in those cases involves referring to other providers or more typically, collaborating with them. But instead of those cases, today we discuss some intersections between behavior analysis and mental health. If you’re board certified or licensed you’ll want to keep a copy of your field’s ethics code handy (here’s mine, as a BCBA-D). If you’re a family or team member wondering about these connections, read on.
No matter your certification, it’s never ethical to work completely out of one’s boundaries of competence. However, it’s also true that applied behavior analysis has supported individuals with mental illness concerns (including those with symptoms of challenges such as schizophrenia) since the field’s very beginnings. Young BCBAs without historical education in the full range of our field’s applications might have been surprised to see the transformation on some 1950’s psych wards of a population with various psychiatric disorders as patients changed from non-social and despondent individuals to interacting with their peers and their behavior analysts. They met goals they set for starting to take care of themselves again as they got dressed, talked more with peers, worked, visited families, and traded in tokens they earned for individual items they wanted to earn, such as a radio to keep in their room. In the earliest days of applied behavior analysis, Ogden Lindsley and colleagues used reinforcement schedules and behavioral apparatus to analyze psychotic behavior and to reveal that it was subject to operant mechanisms just like other behavior. Behavioral treatment of schizophrenia, in that area, became robust, effective, and almost commonplace. For example, Kurt Salzinger analyzed the verbal behavior of persons with schizophrenia and showed that it was related to discriminative stimuli and consequences of people around the patients (Salzinger and Pisoni, 1958, 1961).A later literature review of articles between 1959 and 1972 (Stahl and Leitenberg, 1976) showed that across 23 articles describing programs for psychotic and chronic mental patients, the individualized behavior programs were widely and substantially effective, producing large improvements in the behaviors that were targeted. History students might enjoy Stephen Wong’s “Behavior Analysis of Psychotic Disorders: Scientific dead end or casualty of the mental health political economy?” (Wong, 2006).
But don’t forget the important caution I mentioned while beginning this section: Without training and expertise and supervision in a given population, any work, no matter your field’s history, is still out of one’s scope. Even so, for those behavior analysts with a more limited history, there are still the vast literatures on the empowering use of self-management to change addictive behavior, manage anxiety, self-monitor triggering situations and select and strengthen one’s own coping skills. These are widely used and well researched. In fact, before there was ACT (or Acceptance and Commitment Therapy), there was self-management. (For a good introductory text on behavioral self management see Alexandra Logue’s Self Control: Waiting Until Tomorrow for What You Want Today). Wherever social contingencies matter, behavior analysis can generally help.
Although using behavior analysis in mental institutions generally fell out of favor decades ago, it has been markedly effective in my last few years of work helping others with mental illness learn skills needed to transition to meaningful lives outside the institution, sometimes after decades in those facilities (or years in group homes, foster homes, and inpatient units). Here, the behavior analytic skills of systems support and functional assessment have been useful for teaching teams how to support individuals who had nearly given up on finding a more permanent home.
Collaboration with providers
What someone needs most and first is sometimes collaboration and support, not an intensive 1:1 ABA session. For my clients with mental illness or mental health needs, it has been extremely helpful to:
-get the entire team on the same page
-look at what has been going wrong (e.g., review incident reports and challenges that have repeatedly plagued the attempts to help the person)
-discover what the team wants
-find out what has been a recurring problem? What is keeping the client from the life they want? Who cares about the client and what skills are missing?
-establish communication protocols for the team
-find out what behavioral and other strategies were already in place and whether or how they are working (Often, a team has been using a token system, or behavior plans, or consequences, or attempts to change behavior using antecedents or instructions and modifying motivation, before a behavior analyst ever entered the picture. Our job is to document what has been done and how this has worked; along the way we can often help an entire agency understand how to make their routine interventions more ethical and effective.)
When I have gathered all of that information plus interviewed team members and my client, documented my review of reports, other supports, and the contributions of medical, historical and childhood factors and the client’s and team goals, I have the makings of a behavior assessment and am able to begin sharing recommendations with the team. These recommendations may include more appropriate and consistent strategies, additional documentation of risks to the client and their community, and training on treatments and ways of interacting that may be more effective and helpful to the team and client than what has been attempted in the past.
Stop for a minute: does all of this suggest that a client is necessarily out of a behavior analyst’s scope of service because they struggle with mental illness? No; furthermore, nothing suggested here discounts the important roles of mental health counselors, psychiatric nurses, social workers, psychiatrists and psychologists, and the other members of the treatment team. If anything, my past several years of work has taught me that a good collaboration has usually resulted in making their roles work even better.
Another way behavior analysis is involved in mental health is the important need to protect our own mental health.
In our line of work, we must be able to respond compassionately and calmly to burned-out staff or clients whose behavior “targets” us, perhaps physically, emotionally, or all of the ways a staff person can be targeted or hurt in the line of work. A recent and excellent training on ACT for intellectual disability shared studies in which it helped reduce staff burnout and increase engagement with clients. These two are related, for when I am healthy and calm I can respond more appropriately and consistently to my clients. Since my clients are often staff, it also helps when I train them in techniques that will help them maintain consistency and calm when they are confronted with the daily grind of their own jobs.
One of the simplest yet most effective interventions is arranging an enriched environment—it grows neurons, increases social behavior, and supports virtually every population. Although it can take less time than waiting and intervening in crises, it is not something an inpatient staff can or wants to do when burned out.
When I teach staff how to stay calm and respond calmly and with preventative input (e.g., my preventative schedule or NCR approach), this is often a burnout-protective approach. It IS behavior analytic, but it’s not complicated.
Connections no one planned
Mental health and ABA are also connected accidentally, when a mental health therapist learns their client is receiving ABA, or a behavior analyst learns their client has also been diagnosed (e.g., anxiety, bipolar disorder, PTSD, or others). In these moments we are forced to look at the connection: what do we do to support the client? Ethically, perhaps we should reach out to learn how the family feels about collaboration; maybe the psychiatric team would love to hear how we are supporting behavior change at home or school and how the data change when medications are changed; or maybe there are important risks to document, or helpful suggestions to make that would help the team stay on the same page. Yet often one or more parties says “not my role!” and makes no efforts to implement connected support. Notice again this is still not suggesting to go outside your role, but to work more collaboratively with others as much as it is appropriate (e.g., Ethics Code 2.03a-b).
Taking care of myself
Finally, here are some other simple behavior analytic strategies that help me manage and protect my own mental health so I stay focused and available to bring my best self to client interaction.
Manage my schedules of reinforcement
I carve out time for myself daily- I make time for tea, breakfast and stretching- all important preventative appetitive things I need to approach regularly.
Set up and honor stimulus control strategies to decrease my exposure to stressors
-Take off email notifications on my phone: Sure, you don’t have to answer them, but how many times has one subject line told you about an upcoming stressor, increased your heart rate, or interrupted your use of coping skills or important family time?
-Limit checking email to when you are prepared to respond (not necessarily by hitting reply, but read it and respond by writing a note you’ll save and send later, perhaps). (If scrolling through my account before bed I notice an inflammatory email, I can pause and return tomorrow. I recently practiced this—stopped reading past the subject line until the morning, and first meditated and had breakfast. It was still upsetting but I found that I was able to answer it and move along).
How do you think behavior analysis and mental health are connected? We love to hear your input, stories or questions.
Selected references and resources
Anthony Biglan, Georgia L. Layton, Laura Backen Jones, Martin Hankins and Julie C. Rusby, The Value of Workshops on Psychological Flexibility for Early Childhood Special Education Staff, Topics in Early Childhood Special Education, 32, 4, (196), (2013).
Lindsley, O. R. (1960). Characteristics of the behavior of chronic psychotics as revealed by free operant conditioning methods. Diseases of the Nervous System (Monograph Supplement), 21, 66-78.
Lindsley, O. R., & Skinner, B. F. (1954). A method for the experimental analysis of the behavior of psychotic patients. American Psychologist, 9, 419-420.
Salzinger, K., & Pisoni, S. (1961). Some parameters of verbal affect responses in schizophrenic subjects. Journal of Abnormal and Social Psychology, 63(3), 511-516.
Salzinger, K., & Pisoni, S. (1958). Reinforcement of affect responses of schizophrenics during the clinical interview. Journal of Abnormal and Social Psychology, 57(1), 84-90.
Stahl, J. R., & Leitenberg, H. (1976). Behavioral treatment of the chronic mental hospital patient. In H. Leitenberg (Ed.), Handbook of behavior modification and therapy (pp. 211-241). Englewood Cliffs, NJ: Prentice-Hall.
Stephen Wong (2006). Behavior analysis of psychotic disorders: Scientific dead end or casualty of the mental health political economy? Behavior and Social Issues, 15, 152-177.
This article is Part 10 in an ongoing series about ways that behavior analysts can practice in a “trauma-informed” way. Considering that behavior analysts need to be ready to participate with medical and other providers, this article shares some lessons learned about becoming involved with the medical team. Whether your client is going through trauma or not, it should be helpful. But it’s particularly important for my clients who are being treated in intensive settings for their mental and medical health (often resulting from years of trauma). Be well, Dr. Camille Kolu Ph.D., BCBA-D
One of the ways I like to learn from others is hearing their “lessons learned”. By listening to them share what they have learned and what did or didn’t work, I can hone my own role and be more prepared the next time I enter a similar setting. For many of us, the mental or medical hospital is a new frontier. What can we behavior analysts can do to help in this type of setting?
I think about my role this way: As a behavior analyst, I am not the person’s medical doctor. But we often need to collaborate- and yet most medical professionals are not extremely familiar with collaborating with us. What can I do to support our mutual clients, making their healers’ work more effective?
Here are some ideas that have helped me to integrate into these settings more effectively. In some cases they are lessons I learned when I failed to do something up front that could have made a marked difference later on. In all cases, we have an ethical imperative as behavior analysts to get a medical perspective (or to rule out medical concerns) when there might be a medical component to behaviors that are challenging… but most home and clinic based behavior analysts don’t typically work in the hospital settings.
Cusp Emergence 