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Behavioral Seismology

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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:

  1. PCOS or polycystic ovary syndrome
  2. PMDD or premenstrual dysphoric disorder
  3. Perimenopause and
  4. 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.

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Behavioral Seismology References by Topic

Introduction to behavioral seismology:

Behavior Analyst Certification Board. (2020). Ethics code for behavior analysts. Copyright © 2020, BACB®, All rights reserved.

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)

Click to access MenstruationAndMenopauseAtWork.pdf

https://casadesante.com/blogs/pcos/pcos-fmlapcos/pcos-fmla
Is PMDD a Disability? Workplace Challenges and Accommodations

Click to access discipline-q-a.pdf

Disciplining Students With Disabilities
https://www.prevention.com/health/g43724095/best-period-tracker-app/

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).

What happens when a BCBA-D gets lessons from domestic violence specialists? 6 strategies to take to heart

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Posted by in adults, BABA, Behavior Analysis, boundaries of competence, collaboration, Community, conferences, continuing education, ethics, TI-ABA, TIABA, TIBA, trauma, trauma-informed behavior analysis

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(An article in the TIBA series by Dr. Teresa Camille Kolu BCBA-D)

One day this spring, Dr. Camille of Cusp Emergence sat down to answer a few questions, and learn a LOT, from Enasha Anglade of LaughLoveLive Again. (You can learn more about Enasha and her work on Episode 87 of the Behaviour Speak Podcast!) Enasha and her fellow researcher and BCBA, Stephanie, talked with Camille about how Enasha’s company and work applies behavior analysis to supporting individuals affected by domestic violence. (And did we mention this dynamic duo will be presenting at BABA this weekend?! Go find them if you’re there!) We also discussed some of the barriers people face in this special context. Not all barriers can be solved with behavior analysis, of course, but there are many things we can do to insure we are minimizing the ones we know about, always staying open to learn about the client’s experience and special context. Each of the headers below reflects an important point heard from Enasha and Stephanie and some thoughts from a trauma-sensitive and behavior analytic perspective.

  1. First, be safe.

Interested in getting involved in working with this population? First things first: it’s really important to be safe for someone. This may seem like a no-brainer. In fact, providing a safe starting place for your therapy is where all trauma-informed support begins, even if (and especially when) your therapy is not treating the trauma itself, but solving problems or building skills or meeting needs related to it. However, there are so many ways behavior analysts violate this number one rule. We might do it unintentionally, such as when we go right to changing behavior instead of listening to a person’s experience and what they truly need first. While there are many trauma-informed resources out there on establishing safety and trust, you can also check out a course on building trauma-sensitive environments (starting with safety), or read a behavior analyst’s discussion on safety in Rajaraman et al.’s 2022 paper on trauma-informed applications of behavior analysis. But don’t skip asking the person how they feel safe and whether there are things you are doing or saying that contribute to their safety or their experience of danger. That’s right- behavior analysts can inadverdently present danger signals to our clients in many ways. When someone is in the middle of a dangerous situation, they are in survival mode and not ready to learn. We don’t want to trigger this for a client and we don’t want to make worse a situation that already exists for them. Being safe (and making sure our presence and therapeutic environment are safe) is not about helping clients avoid all aversive, challenging, or difficult circumstances. Our clients (especially in this context of domestic survivors) are already going through one of the difficult things in their lives. Coming for help and walking out of horrible situations may be even harder than what they’ve been through before… it will be unfamiliar, may be incredibly risky, and may occur at great personal cost to them. What they’re doing is brave. They’re already doing the hard thing. This is about taking their hand and really listening to what they’re going through.

2. Don’t be afraid to go there… but secure support for yourself so your client does not have to do the work for you

Speaking of listening to what they’re going through, behavior analysts can be bad at listening. Does that sound strange? Behavior analysts are great at observing, typically by nature and training… but we can learn to be better listeners, too. And it’s CRUCIAL in this work. Enasha notes that we are often afraid to be personal, to “go there” with our clients. For behavior analysts in the trenches of severe challenging behavior, we’ve often gotten our hands dirty, literally. But to understand our clients coming from domestic violence, being a witness to their story can be meaningful. Listen to your client. Listen long enough to hear. Listen enough to learn what they could benefit from, too. She may need a counselor recommendation, a connection to somewhere she can forge a meaningful relationship, or a tool that you can’t provide (but that someone you know, could). Their daughter may need help for something you don’t treat. Most important, listen to help your client, not just to facilitate your client’s progress with your program.

Related to “going there” with your client, make sure you are not a burden on THEM. If their issues trigger you, your session with them is not the time to discuss that. Of course, there’s nuance involved in learning to listen to someone, so it would be helpful to do any or all of these suggestions: secure your own therapist to go to if you are troubled; be prepared by using specific ACT and mindfulness techniques that keep you able to use your flexibility skills; help your staff debrief with pre-planned supportive interactions after difficult client visits; learn more about motivational interviewing (for a constructional approach from a behavioral perspective see Goldiamond’s constructional interview); and provide training for you and your staff from a trauma expert outside behavior analysis to answer questions about how to support someone disclosing difficult material).

3. Value relationship over rapport, but in the right way.  

Your program isn’t everything. Behavior analysis doesn’t solve every problem (despite Skinner’s ideas about saving the world and articles by more contemporary well-intentioned behavior analysts interested in supporting human beings). But your relationship with your client might matter more than you think. And I’m using the word “relationship” instead of “rapport” on purpose. (This section could also be titled, “De-centering us, and behavior analysis, while putting a higher priority on that person and what they need”.)

Of course, if we were talking about real rapport, in the way the layperson uses the term rapport, we’d be talking about the same thing as relationship. The word rapport just means “a close and harmonious relationship in which the people or groups concerned understand each other’s feelings or ideas and communicate well”. But in behavior analysis, the word rapport typically connotes a more transactional process, one used as a procedure as a means to an end. Ultimately, many behavior analysts view rapport as a process one includes in the beginning of sessions or relationships with clients so that clients will be more likely to approach the instructor, and so that the instructor can deliver instructions, reinforcers and other environmental stimuli that encourage the client to change their behavior in specific ways the team has defined and prioritized.

Relationship viewed as an end is different. It has benefits beyond the program. It validates the person and prioritizes their needs. You might think of the way that with a relationship between two people who care about each other, we say goodbye when we’re done. We don’t just transfer off the case without letting the family know because we got a new job, or our hours were cut. However, we’re also not suggesting behavior analysts engage in dual relationships with our clients (an unethical and unhelpful practice to be sure!) What we’re really saying is to value the person over momentary instructional control, and treat them… well, like a person. We still need to be careful, and cautious, to preserve the integrity of precious boundaries. In other words, you are still not going to show up as your client’s “friend”, and you need to teach them, lovingly, how this will work in the beginning of your therapeutic relationship with them. You care about them, and you care enough to support them with their goals. That may include finding friends, or engineering environments that facilitate their making friends, but that’s not you; you’re the therapist. You can still be a good listener, care about your person, and support them without being their friend.

We can program toward the end the entire time, so that there is no disruptive surprise for the client at the ending of the relationship. I like to think about this as fading out interactions to a very low rate that is tolerable, and with programming additional sources of reinforcement for the client. Being the only person your client can trust wouldn’t be helpful; what if you were to have a car accident, move away, or have to reduce your hours? All those things happen, but if you plan from the beginning, you can insure they happen in more therapeutic ways. Be really careful to use ethics code guidelines on transferring cases, especially when you are working with someone in a sensitive and vulnerable situation like those surviving domestic violence.

4. Accept this: any behavior can be influenced both by its consequences in the moment, AND the relevant context and history.

When loud voices in the room ask “what does history have to do with behavior? Shouldn’t we just treat the function that’s controlling it now?”, it can be tempting for vulnerable behavior analysts to question themselves. Should I even be taking a trauma-sensitive approach? Should I take this person’s history into account at all? If it’s just paying off for them in the attention it produces, and we technically know about methods to turn behavior on and off using procedures based on consequences and arranging stimulus control conditions, what does it really matter?

Actually—in terms of bringing up trauma, or changing goals based on it—the answer may vary depending on what the client needs! CuspEmergence doesn’t recommend taking a trauma-informed approach when clients don’t need it. But those going through domestic violence all have been through trauma, by definition. As Rajaraman et al. (2022) states, “Responses to trauma may indeed vary from person to person; however, ACEs are well documented, and a preventative TIC approach would acknowledge their potential impact”.

We recommend behavior analysts working with survivors of trauma be intimately acquainted with the ways trauma relates to behavior, to medical needs, to subsequent challenges and needs, and to the barriers people face in moving on to healing circumstances. (See the sections nearer the end of this article for educating your team if that’s not your forte). And yes, behavior can be influenced by BOTH history (such as the trauma-related factors that were present when someone began to use behaviors that are now difficult for them and they want to change, even if those behaviors are NOW maintained by other environmental factors).

Because behavior is at any moment a function of the dynamic interaction between the local and historical context, it is possible that the intervention strategies identified during the functional assessment phase as “likely to be effective’ will need some modification when it is actually time to intervene. As Stephanie notes, clients affected by domestic violence may face unpredictable and changing needs. The needs of the client demand that the analyst be flexible and sensitive to the contingencies and challenges our client faces. We should be especially focused on tracking the ways we might be contributing (perhaps unintentionally) to coercive cycles of interaction for our client, perhaps hindering their growth by playing in to a power differential or offering choices using an architecture that WE don’t perceive as, but the CLIENT experiences, as coercive.

5. Identify the basic training your team will need. What are the most essential and meaningful training components your staff will need? Who provides that training, and how can you value it at the levels of culture, group, and individual?

What happens when most of the team cannot relate to the particular difficulties with which a client is struggling? They might recommend changes that are not feasible to the client; they might miss danger signals the client is sending based on what is happening around the client (and miss an opportunity to prevent harm); they might take personally or misunderstand the challenges a client is having and miss crucial chances to intervene appropriately; they might cause harm by actions intended to help; and so much more.

One team we know used to have a person on staff who provided this training because she had been through it, but her caseload is now too big for her to spend time with each new staff person. As the team grew, the personalized approach they were known for was eroded and eventually, the services they provided looked like most other agencies, and they were no longer meeting the individual needs of client families. However, they didn’t know it until they received feedback, because nothing had been intentionally changed; it was simply a product of drift that happened with the welcomed growth going on.

So one solution for teams with similar paths is to prioritize providing training from a reputable and experienced source, and doing that both routinely and in a way that continues to answer questions the new team members will have as they gain their own experiences and put their previous knowledge into their new context. In a subfield like domestic violence, this training needs to come from someone either outside of behavior analysis, or from someone whose training, expertise, experience and culture strongly intersects with that of the clients and their needs. If this person is not on staff, it is essential to secure regular training, as well as embedding this as a priority into the agency’s mission, core processes, values at work, and interacting with clients. Staff should not have to ask for designated and regular times they will be paid to access and discuss and apply the training (and receive appropriate feedback from someone equally experienced and trained).

6. Identify the most important kinds of support your clients will need that you cannot or do not provide. What kind of support is needed, who else provides it, and what would you like to be doing in 5 years if you removed barriers related to this support?

The first part (who else provides this?) is a logistics question. Prioritize finding those answers right NOW. If most of your clients receive behavioral support from you, but also need to be able to access certain other resources to survive, find out all about those resources and who provides them.

The idea is that you can position your agency in the middle of a network to which you can connect your clients. You do not want them struggling, alone, with something that could make or break their ability to come back to access your services or to implement them. We can start small, beginning with very simple connections you provide your client, such as a list of websites, phone numbers and connection names for partner agencies in your area that meet big needs (and funding options for those needs).

The second part (what would you be doing in 5 years if you removed obstacles?) takes more planning, but might make sense strategically depending on your clientele and their challenges. Some of the solutions could include creating a part- or full-time position of Resource Coordinator, hiring a social worker, or forging a strategic partnership with someone who fills this role for other companies and who knows your area well and can devote time to your own clients on a weekly or regular basis that makes sense for your client volume.

Do you do this work yourself? Contact us and add your essential strategies. Want to learn more? Find Enasha and Stephanie at BABA, listen to the podcast (Ben is in Detroit right now documenting BABA 2023!), follow ACES and ABA groups on social media, send us a comment and leave us your email below, or take a course on trauma sensitivity. We hope to hear from you soon!

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New 4h course: Autism, TIBA and Ethics

02 Wednesday Feb 2022

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!

25 Things I Want You to Know: Ways I use trauma to inform my practice of behavior analysis

26 Thursday Aug 2021

Posted by in adults, Autism, BACB CEU, Behavior Analysis, boundaries of competence, CEU, children, collaboration, Community, continuing education, contraindicated procedures, Cusp Emergence University, CuspEmergenceUniversity, Education, mental health, resources, risk versus benefit analysis, TI-ABA, TIABA, TIBA, trauma, trauma-informed behavior analysis

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This is the 21st article in a series on Trauma-Informed Behavior Analysis by Dr. Camille Kolu, BCBA-D

I often hear from educators and behavior analysts, “What do you actually do differently if your client has faced trauma, given your role as a behavior analyst?” In this bulleted series we’ll get there, but we’ll start with what I would want you to understand about myself as your client (or teammate!) who has experienced adverse experiences. Here we list 25 different things I want you to know. (As a hint, each thing we can understand about a person could be a bridge, if you choose to walk through this difficult thing to a shared place of understanding on the other side. We’ll explain in more detail in future posts, or you can check out our course library over at CuspEmergenceUniversity if you’re interested in expanding your boundary of competence). But first, if I were your client or team member – if my past involved trauma – I would want you to understand that now, with the presence of historical trauma,

I MAY:

  • have difficulties calming down when under pressure
  • have difficulties using “appropriate” behaviors even after years of programmed reinforcement for using them
  • have mental health concerns that have never been appropriately addressed because my behavior masks my needs
  • have medical problems that are going unaddressed because my providers have never asked me about my trauma history, despite it being a fact that it confers serious medical risks. (See the incomparable Nadine Burke Harris talk about her work on this, and the amazing takeaways, in her classic TED Talk– or see some of her research and outcomes on using screening tools)
  • be more likely to use certain “challenging behaviors”
  • and find it more reinforcing, even important, to use behaviors you would describe as challenging
  • use behaviors that are more resistant to change than you are used to as an instructor, therapist, parent, supervisor or friend
  • find certain interventions painful, difficult, or harmful
  • find some kinds of social interactions difficult or painful
  • have trouble controlling some of my bodily functions, but may not be able to describe to you why
  • experience “triggers” in the environment that you can’t see (but that an experienced provider could locate, document, and learn to help me explore or move with, as appropriate)
  • experience some times of the day, week, month, or year that are marked by aversive events for me that you won’t know about
  • may not be able to explain WHY this time is difficult or why I am using an “old pattern of behavior”
  • find it more difficult to perform, or to learn and remember new things than others of my age, skill level, or occupation – even if “on a good day” I can do this just fine. (By the way, have you read The Four Agreements? Do you know how important it is to take nothing personally and know that others are doing their best (and how critical it is for you to do the same)? If not go check it out.
  • use occasional behavior that is mistaken as “ADHD” or “ODD”, or more, but that is actually related to how I was mistreated
  • have been given misdiagnoses, treatments that didn’t work, or medications that made my problems worse or that interacted with each other in harmful ways that hurt my body and cognitive function
  • attempt to advocate but get ignored when I try to communicate pain, mistreatment, or a medical concern
  • be more likely to experience FUTURE trauma because of what I faced before
  • lack a reinforcing and useful repertoire (e.g., full complement of skills and things to enjoy), especially if I faced treatments that just tried to “teach me a replacement behavior” for a few challenging things I did, instead of understand and grow me as a person in the context of my own community, needs and desires for my future
  • be part of a long line of marginalized people or one of multiple generations exposed to trauma
  • have a chance to change our lineage… if you help

After all, I AM:

  • a human being with interests, feelings, and great potential for growth and joy
  • more likely to experience certain risks (I may be at greater risk of losing my educational or therapeutic setting, go through harmful discipline practices, be exposed to law enforcement interaction, for example)
  • in need of understanding, an informed supervisor and system of support, and someone who will document my challenges so we can work on them, but not emphasize them so much they ignore my strengths, needs and skills
  • capable of much more on my best day than I show on a hard day… but I am always doing “my best” at the time, given what I have been through and what I AM going through, and despite what it looks like

Taking these points as a starting place, future posts in this series explore what I NEED as a person who may have faced these things, and what I DO as a behavior analyst who cares. We’ll also share some of what I need from my supervisors or systems administrators! What would you add to this list? What are some of your action items?

Self-paced SAFE-T Assessment Training is here!

16 Tuesday Feb 2021

Posted by in adults, Autism, BACB CEU, Behavior Analysis, behavior cusp, Behavioral Cusp, CEU, children, collaboration, Community, continuing education, contraindicated procedures, Cusp Emergence University, CuspEmergenceUniversity, Education, ethics, mental health, resources, risk analysis, risk assessment, risk versus benefit analysis, supervision, teaching ethics, TI-ABA, TIABA, TIBA, trauma, trauma-informed behavior analysis, Uncategorized

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It’s finally here! We have learned so much from workshop attendees, trainees and supervisees in this area over the past several years, and appreciate the attendance, feedback and support of everyone who has taken the training or used a version of the SAFE-T Assessment. Coming on Monday, the booklet and training for assessing trauma-related factors affecting our clients of behavioral services, are available ONLINE as a self-paced course. This course provides a download of the new and expanded SAFE-T Checklist booklet, which contains several tools enabling the screening and documentation of over 200 trauma-related factors, and a Risks and Needs form to help teams understand (and document) how these factors confer risks (and converge in risk factors that must be solved or mitigated to protect our clients, teams, and ourselves). The booklet contains an extensive reference section and team supportive tools as you use your new knowledge to better align your team’s skillset with the Ethics Code, and the individualized needs of behavior services clients after trauma.

Several of our behavior analytic and collaborator clients across institutions, educational facilities and private companies clients have shared that learning to assess risk factors related to trauma, and to apply this information to their teams’ FBAs and risk mitigation plans, took their skillset to the next level – essentially affording them an opportunity to acquire an important behavioral cusp for their teams.

Some new components of the booklet include:

  • An optional buffer/ resilience score to assess whether protective environmental and therapeutic components of a client’s plan are in place (to understand some ways that trauma gives rise to medical and behavioral challenges and some buffering factors that can help, please see the book or scholarly articles by Dr. Nadine Burke Harris (e.g., Oh D.L. et al. 2018), who is the Presidential Scholar for 2021’s upcoming Association for Behavior Analysis International’s conference. She will address the critical topic of breaking the intergenerational cycle of adversity, and screening for ACES (adverse childhood experiences).
  • Table of potentially contraindicated procedures (cross referenced with items and risk clusters assessed in the Risks and Needs form)
  • Information about over 50 risk clusters (groups of related risks in the 6 assessed sections of the SAFE-T Assessment)
  • Cross-reference tables showing, for each item we screen for, the location(s) in the SAFE-T Checklist
  • Infographic on components of a trauma-informed FBA
  • Brief templates for Risk Versus Benefit Analysis and Risk Mitigation Planning
  • The IPASS (Inventory of Potential Aversive Stimuli and Setting Events) tool and instructions
  • References (organized by topics) covering over 40 areas or topics of literature related to trauma (including relationships of ACES to medical problems, ACT and intellectual disability, ACT and anxiety, foster care and adoption, the relationship of abuse to pain, drug use and trauma, and much more).

Time required: The course includes about 4.5 hours of video content in 12 lessons, each followed by a brief quiz.

Price (includes 4.5 CEU course and SAFE-T Assessment booklet download): $189.99

For $20 off through the end of February, use the coupon code “SAFET20”.

To register: cusp.university

Contraindicated behavioral procedures after trauma

08 Tuesday Sep 2020

Posted by in adults, Behavior Analysis, collaboration, continuing education, contraindicated procedures, Education and Trauma-Informed Behavior Analysis, enriched environment, mental health, praise, RAD, reactive attachment disorder, risk versus benefit analysis, schedules of punishment, TIBA, trauma, trauma-informed behavior analysis, Uncategorized

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This is the 20th article in a series on Trauma-Informed Behavior Analysis by Dr. Camille Kolu, BCBA-D

In medicine, contraindicated procedures are those that are withheld due to the potential harm they might cause to a patient. More and more, behavior analysts are interested in learning about someone’s history, in part to lessen the risk they will do a client harm.

We are tasked, ethically, to do no harm (and see the BACB Ethical and Professional Code item 4.02); to evaluate potential risks and side effects of interventions and to weigh the possible benefits of each (see 2.09 and 4.05); and to avoid using harmful reinforcers or those that require excessive motivating operations to be effective (4.10).  For RBTs as well as those certified at higher levels, ethics obligates us to protect our clients from harm (see RBT Ethics Code section 2.02).

In our live webinars (please see CuspEmergenceUniversity.com where we list topics we train frequently on– any course you see there is available as a live webinar training or, in some cases, available as an on-demand training), we receive frequent questions like this:

What kind of procedures should be avoided when working with a new client after certain types of trauma? Are there certain procedures we should give more thought to after a client has been through challenges we know about? What do we do if so?

Given these wonderful questions, today’s post shares a few basic procedures that may be contraindicated – at least at first—given a specific combination of historical factors involving trauma.

Of course, it’s not black and white. Often this should just be the first step for the team, a conversation in which people consider potential for risk conferred by historical variables. The team can then make a more careful decision in order to mitigate possible risks and maximize the benefit of any procedures selected, along the lines of what our code suggests in item 4.05. Though each procedure below is potentially contraindicated at first, it could be appropriate later in treatment, or perhaps from the beginning- the point is that this should depend on an individualized risk versus benefit analysis of the other options available to the team, the client’s history and needs, the severity of the past abuse or neglect or trauma, etc.

  1. For a client who has experienced previous food insecurity, food related abuse or neglect, and/or severe food deprivation:

One potentially contraindicated procedure is using edible reinforcers.

Notes: Here there are risks to the client, and also potential risks to the client’s relationship with their caregivers and team members. The conditions necessary to establish the motivating operation for reinforcement may be similar to previously neglectful or abusive conditions, or may act as conditioned motivating operations that make harmful behaviors temporarily more likely. In our history treating clients after these circumstances, we have also experienced something related to behavioral contrast in this situation. For example, a client who was provided edible reinforcement in their new applied behavior analysis setting then went home and used dangerous and surprising behaviors related to their neglectful history. The client’s foster family was caught off-guard by these new behaviors, but they could have been predicted during team education on how edible reinforcers might need to be avoided at first when conditioning new team members as reinforcing (and as instruction-related discriminative stimuli).  

2. For a client who has been involved in previous sexual abuse (including when the client also makes allegations):

One contraindicated procedure is assigning a 1:1 without additional oversight.

Notes: Here there are risks to both the client and additional team members. When the team receives this case, it would be contraindicated to immediately assign 1:1 support without preventative measures such as training for the 1:1 and supplemental recording, additional oversight or whatever is deemed necessary.

3. For a client who has experienced medical complications from sexual or physical trauma (e.g., this could include incontinence, fecal smearing or related concerns, etc):

One contraindicated procedure is conducting toilet training without oversight from a medical professional, additional training or consultation by someone with expertise in this circumstance, etc.

Notes: In this situation, respondent and operant interactions can occur that are dangerous to treat without expertise; the client can risk serious complications and worsening medical problems; there is a risk of further conditioning the experiences of voiding (and related rituals) as aversive; there is a risk of occasioning behaviors related to the past abuse, or pairing aversive events with team members involved in the procedures; and more.

4. For a client who has experienced previous neglect or adverse circumstances (such as deaths of parents, removal from unsafe conditions, or experiencing war, dangerous immigration or poverty related issues), resulting in deprivation of basic needs and social interaction:   

Some potentially contraindicated procedures involve attention related extinction, differential reinforcement of appropriate versus inappropriate requests, or time out from attention reinforcement.

Notes: In this situation, there are safer procedures to begin using that could avoid some of the harmful side effects of removing attention contingent on unsafe behavior. A child with a serious history of neglect may have used behaviors that can seem bizarre or out of context for typical child development, but that were critical to the child’s survival. At the same time, it may not be appropriate to pair new team members with procedures that were used in the child’s neglect, even if the “intent” is different. There are many procedures that can be used more safely, such as using enriched environments and fixed time schedules, to provide monitoring, insure high levels of safe attention, and begin to condition adults as neutral stimuli again, if needed, after harmful interactions with adults in the person’s past.

5. For a client who has been affected by physical and/or sexual abuse, behaviors and circumstances consistent with reactive attachment disorder, or multiple and changing caregivers in childhood:

One potentially contraindicated procedure might be contingent praise statements to establish compliance related behaviors.

Notes: In this situation, a client may have had a history in which adults could not be trusted, behaved inconsistently or inappropriately, or paired unsafe and harmful actions with typical caregiving behaviors. Clients who experienced this may initially present as lacking “a compliance repertoire”, but it may be contraindicated to attempt to establish and praise compliance, for several reasons. Some may be overly compliant, and lack self-help and self-advocacy repertoires that are critical to autonomy; if they are still going home at night after the school day to an unstable situation or multiple foster homes, to praise rigid compliance may increase the risk of further victimization or contribute to future abuse. At the same time, initial praise for compliance may damage relationships between the client and new caregivers who have not “earned” the right to praise the client’s behavior by establishing a history of consistency and helpful interactions. Furthermore, praise might already be conditioned as aversive for the client and could sabotage the caregiver’s attempts to establish a relationship or instruct appropriate behavior. (CuspEmergence.com has written elsewhere about praise here).

6. For a client who has been affected by neglect, and involved with law enforcement, suspensions and challenging behavior:

A potentially contraindicated procedure is least to most punishment.

Notes: Implementing punitive procedures (or procedures that educators assume to be aversive and are using to control behavior) in a “least-to-most” order is dangerous, especially after the interactions mentioned here. Any time punishment is implemented in a LTM order, we risk these outcomes: conditioning the aversive stimuli becoming more reinforcing, and more familiar; worsening the client’s behavior as they need to contact more and more of the supposedly aversive stimulus; pairing the people administering the punishment with aversive control, making it more likely the client will (to speak loosely) act out more and more for their high-quality attention; etc. (CuspEmergence.com has written about the potential pipeline from special education to prison here, in an article referencing some of these concerns and containing behavior analytic references.)

7. For a client with symptoms or diagnosis of trauma-related disorders or needs:

A potentially contraindicated thing to do is recommending or implementing applied behavior analysis without any mental health or trauma-focused treatment or input.

Notes: Behavior analysis (at least the kind I provide and teach about) is not a trauma treatment. We are also not a source of diagnosis for trauma. Instead, I work in a complementary way with a team and/or family that is interested in learning about risks related to trauma history, and how these risks affect the person’s behavior, needs, and supports. There are therapies that can provide trauma-focused treatment and aid a person to heal after experiencing difficult circumstances; a person may need these in addition to, or before, receiving behavior analysis to aid them in developing a safe, expanded behavioral repertoire. If someone trusts you with their trauma history, please be careful and supportive.

In closing, for a client with a specific conditioning history, the contraindicated procedure would likely involve aversive conditions and potentially medical or biological variables. Always consider items 3.02 and 4.08 from our Professional and Ethical Code, and discuss whether they apply to your case:

3.02 Medical Consultation. Behavior analysts recommend seeking a medical consultation if there is any reasonable possibility that a referred behavior is influenced by medical or biological variables.

4.08 (d): Behavior analysts ensure that aversive procedures are accompanied by an increased level of training, supervision, and oversight. Behavior analysts must evaluate the effectiveness of aversive procedures in a timely manner and modify the behavior-change program if it is ineffective. Behavior analysts always include a plan to discontinue the use of aversive procedures when no longer needed.”

Upcoming: Brief webinar series on TIBA in partnership with Connections-Behavior.com

28 Thursday May 2020

Posted by in adults, Autism, BACB CEU, Behavior Analysis, CEU, Community, continuing education, Education, Education and Trauma-Informed Behavior Analysis, supervision, teaching behavior analysis, teaching ethics, TIBA, trauma, trauma-informed behavior analysis, Uncategorized

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Now that the annual conference for ABAInternational is past (whew!), Cusp Emergence is excited about upcoming webinars and online conferences (New Hampshire and FABA, I’m looking at you!). First up is a partnership with Connections-Behavior.com: We will look at trauma-informed behavior analysis in two parts, on June 1 and 15. Register here for this CEU opportunity!

Connecting Behavior Analysis, Aging, Trauma, and Supervision

18 Monday Nov 2019

Posted by in adults, BACB CEU, Behavior Analysis, boundaries of competence, CEU, collaboration, Community, continuing education, Cusp Emergence University, dementia, ethics, mental health, supervision, teaching behavior analysis, TIBA, trauma, trauma-informed behavior analysis

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Behavior Analysis, Aging, Trauma, and Supervision (or BATS, in honor of Dr. Janet Ellis).

This is the 18th article in a series on Trauma-Informed Behavior Analysis by Dr. Camille Kolu, BCBA-D. It includes something new that we have been asked about: Companion notes for students and supervisees working through this information with the support of their supervisor.

I heard Jon Baker give a great talk on advances in behavioral treatment of gerontology the other day at COABA. It made me think of my students at the University of Colorado Denver and our supervisees. (There was also a fantastic talk on supervision and feedback by the incomparable Ellie Kazemi, whose book on supervision is out now). When they ask about clients other than autism who have benefited from applied behavior analysis, my supervisees are usually excited to read stories in which ABA changed the lives of people with dementia, brain injury, medical needs, and more. For example, an article from Baker (2006) Continue reading →

“Trauma-Informed Behavior Analysis” is redundant. Here’s why I use it anyway.

03 Monday Jun 2019

Posted by in adults, Behavior Analysis, boundaries of competence, children, collaboration, Community, contextual fear conditioning, Education, ethics, extinction, renewal effect, TIBA, trauma, trauma-informed behavior analysis, Uncategorized

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“Trauma-informed behavior analysis”: Redundant term or useful phrase?

This is the 16th article in a series on Trauma-Informed Behavior Analysis by Dr. Teresa Camille Kolu, Ph.D., BCBA-D.

Trauma-informed behavior analysis, abbreviated TIBA, is a phrase I’ve been using for a few years now to describe what I do to people outside behavior analysis. I do this because it helps them to understand how I apply the science, and not to suggest that “regular” behavior analysis should not address trauma. From those behavior analysts who have not been to my trainings, I often hear the question “Isn’t it redundant to describe behavior analysis as trauma-informed?” I would argue that the short answer to this question is “yes”. However, this article describes why the more important and longer answer is “yes—and it’s still useful”.

About this outline: As one of our current projects at Cusp Emergence, Dr. Camille Kolu is aggregating several years of data (including feedback from existing BCBAs, educators, foster parents, and social workers) in writing a set of articles on the topic of applying the science of behavior analysis to behavior change after a person has experienced significant trauma. This topic comes up frequently on behavior analytic forums. Please note that this brief outline does not describe the SAFE-T model (by which we advocate appropriate supervision, functional assessment, risk documentation, and environmental modification and training) or solutions to all the challenges it raises. Check out the other blogs on this topic, email us if you’d like to provide comments and questions, or see cuspemergenceuniversity.com for CEU and training opportunities.

Background: How is “trauma-informed behavior analysis” redundant?

I. The ethical practice of behavior analysis already requires it.

  1. We individualize (see BACB Compliance Code item 4.03)
  2. We should practice within our expertise (1.02)
    1. People whose lives are changed by major traumatic histories are changed in ways that distinguish them and their needs for specific supports, much like people who engage in serious self injury or have eating disorders are distinguished as a sub population who can benefit by specific expertise and training. We accept clients only if we are appropriately trained (2.01)
  3. We are already tasked with taking history into account, including analyzing functional relationships (3.01) and referring to consultation for medical needs as appropriate (3.02)
  4. We should refer and collaborate when needed (2.03a and 2.03b)

II. The application of behavior analysis already covers it (see Baer, Wolf and Risley 1968, 1987)

  1. Appropriate ABA tackles behavior of meaningful social significance, which it (behavior that is related to historical traumatic or aversive events) certainly is
  2. Appropriate ABA is conceptually systematic, and treatment of behavior after trauma may be conducted within the conceptual basis of behavior science
  3. We already have interventions that can be applicable and effective with this population (see our resources page for a partial reference list) including treatments for post traumatic stress disorder, using acceptance and commitment therapy principles from behavior analysis, and schedule related procedures including NCR for challenging behaviors; or see Fahmie, Iwata and Mead 2016; Iwata, Petscher, Rey and Bailey 2009; Richman, Barnard-Brak, Bosch and Abby, 2015)

III. The underlying science of behavior analysis and work on learning and behavior already describes phenomena related to behavior after trauma (see literature on reinstatement, contextual conditioning, respondent behavior, extinction in multiple contexts, etc)

  1. Laboratory work on extinction challenges from a respondent conditioning perspective can help us understand some of the unique challenges people face after experiencing trauma (see Bouton 2004)
  2. In basic research, “renewal” (return of behavior that was previously extinguished, after exposure to a conditioned stimulus- see Bouton and Bolles 1979; Harris 2000) is stronger with respondent behavior than operant behavior (Crombag and Shaham 2002)
  3. But younger behavior analysts may not have been trained to adequately appreciate respondent conditioning’s effects on behavior, and to teach others how to work with behaviors that are not operant. They may over-rely on using consequences to change behaviors, leading to criticism that “this stuff doesn’t work with my client impacted by trauma”. (Respondent conditioning is an item on both the 4th and 5th edition task lists, although respondent-operant interactions (see 4th edition, item FK-16) has been removed).

The current state: How is the phrase “trauma-informed behavior analysis” still useful (even needed) if it’s technically redundant?

I. I believe it’s helpful to both practitioners and client base.

  1. For practitioners: widespread practicing out of expertise incurs huge risks to clients, agencies, individuals and communities.
    1. Many people assume that the application of behavior analytic principles to trauma affected populations requires no nuances, and have harmed others
    2. There are not widely available risk assessments and tools to help those of us in this subarea document and collaborate as effectively as we need to
    3. There is not a collective understanding of how the collaboration can work, and many behavior analysts proceed unethically (although unintentionally)
  1. For clients: People needing the service are thwarted by bad (or just uninformed) press about ABA or and many think that ABA would be ineffective, harmful, or contradictory to their trauma-informed colleagues’ practice. This phrase gives me a way of introducing my services and assuring the recipients that I
    1. will, and do, consider their history of trauma as something that informs everything I will do for them
    2. will still be practicing behavior analysis, but from this specifically informed perspective
    3. honor both their specific background and their individual needs, using my own training and expertise in behavior analysis informed by additional experiences with social workers, those in the foster family community and others

II.  This phrase also gives me a way in, to talk to groups who haven’t had good experiences with behavior analysis

  1. including professional educators, school psychologists and therapists who have attempted collaborations that failed because clients’ trauma was overlooked or the practices were ineffective
  2. and including foster and adoptive families for whom the practice of “everyday ABA” included go-to strategies that were not (or at least not at first) helpful to their clients
  3. or people who haven’t had ANY experiences with behavior analysis (in my practice this includes people from these groups):
    1. Lawyers and courts
    2. Court appointed special advocates
    3. Social workers
    4. Trauma therapists
    5. Foster families and adoption agencies

Dreaming of the future

My goals include that one day in the near future,

  1. Treating behavior after trauma is a specialty in which behavior analysts can readily obtain experience from several field experts, similar to how they gather expertise specifically in treating behaviors such as severe self-harm, pica, or disordered eating, or behaviors in people with autism or genetic differences, or those in pediatric or geriatric populations.
  2. For recipients of behavior analysis, it will be simple and easy to find several options for treatment for behavior after trauma, from people with appropriate understanding, training and supervision, that can help them and collaborate effectively with other members of their team
  3. There are multiple funding streams to readily serve the population (examples: foster care, social workers, etc)
  4. And “everyday behavior analysis” is no longer viewed as contradictory to the support that would benefit people with historical experiences described as traumatic

Takeaway: I agree that saying behavior analysis should be “trauma-informed” can be redundant, since the basic science is rigorous enough to describe why our behavior is changed after and challenged by trauma. But I use it because it helps communicate what I do to people who have a specific history, and to help other behavior analysts understand how to establish an ethical approach to the intense documentation, risk mitigation, collaboration, and assessment that is required while using existing behavior analytic procedures to support those affected.

What’s your take? Send me a note or share a resource any time.

See or add to our growing reference list related to behavioral treatment of trauma.

Beauty and the Bug: Trauma and individuals who are differently abled

29 Tuesday Jan 2019

Posted by in adults, Autism, BACB CEU, Behavior Analysis, boundaries of competence, CEU, collaboration, Community, continuing education, mental health, Rett's, trauma, Uncategorized

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Beauty and the Bug (in which we briefly explore trauma and non-neurotypical people, ask how to raise tender-hearted children, and see a bug portrait in pointillism)

This is the 15th article in a series on Trauma-Informed Behavior Analysis by Dr. Teresa Camille Kolu, Ph.D., BCBA-D.

How do we teach others to tend the needs of those who cannot express them (or for that matter, appreciate the lesson of loss, the tenderness of pain, the beauty in brokenness)? And how common is trauma in individuals with serious developmental disabilities? Many of us have not considered the relevance, let alone the prevalence. Is this because we can’t see it, don’t hear about it, or think that it is out of our scope to address? These questions occurred to me this week as I thought about a participant from a recent training I provided, who asked if the model of trauma-informed behavior analysis (about which I’ve been writing here) applied to individuals with intellectual differences (it does!). Even to us professionals in the field of behavior analysis, the complexity of and subtlety of trauma and behavior remains elusive.

This week my family lost a wonderful man. He and his wife tended to the needs of others (often before their own). Also this week, my reason for taking a work break turned three months old, and Imagine! (a nonprofit agency in my area) had its annual celebration. As I mulled over these questions about trauma and differences and on raising good people, a therapist friend posted Imagine’s video of one of their clients. I realized I had not blogged before specifically about treating challenging behavior in someone who is differently abled. I need to do that, lest one more reader think that this approach (trauma informed behavior analysis) is mainly useful for “vocal” clients, or those who can easily articulate their pain and past. Today, Shelly and her zany personality inspired me to do this.

Individuals with developmental and intellectual differences express or show their history and needs in different ways, and sometimes caregivers overlook the contributions and signs of trauma, neglect or even ongoing abuse. When we (especially behavior analysts) overlook these, we are not addressing the real reasons for challenging behavior, and we might miss the importance of connecting the person with critical mental health resources, or of offering a chance to heal past wounds. We know about functional communication training. But do we fully address subtle needs to communicate pain—both emotional and physical? And when someone lives in an environment or is exposed repeatedly to a situation or person that is aversive (even abusive!) do we teach them to effectively advocate for removal and communicate their discomfort, or do we merely try to reduce the “challenging behavior” that often accompanies the terrible situation? Do we recognize the signs of abuse in individuals who have few skills to communicate?

Too many times, I took a case where team members requested decreases in “challenging behaviors” in someone with diseases like Parkinson’s, Alzheimer, or Spina Bifida, before the team had recognized that the main thing challenging about the behavior was that it was going on because the individual had NO dignified way out. A conversation with a peer last week revealed that without training in these issues, a behavior therapist or even the entire team might treat “suicidal ideation” as a “behavior to be decreased” rather than a serious problem to be solved. (Even when this “behavior” is partly a habit the person has learned to use as a tool to produce needed attention from others, a whole behavior analysis of the situation would consider the risks and possible outcomes of addressing it in different ways, and document and address the related needs to understand and address why this was happening.)

As Shelly and her team alluded to in the video, the very state of not being able to communicate one’s needs and preferences can be traumatic in itself, and can lead one to develop desperate behaviors that just get called “behaviors for reduction” in the individualized behavior plans of thousands of clients. Today there are no more excuses for not helping someone access and master a communication system that works for them. To be sure, not everyone has access to a Smart Home residence decked out with all the tools we saw on the video- but have you seen the article on an accessible app developed by the brother of a man with autism in Turkey (so that he could communicate needs  and gain leisure skills using only his smartphone)?

Tragically, many of my clients went through abuse and neglect and need someone to write careful and informed behavior plans that teach them skills they did not have at the time, like articulating emotional and physical pain, advocating for their needs, and requesting to be removed from a serious adverse situation. Just as important, these clients need an informed analyst who designs ways that these skills will persist when the client moves environments, as I found when a former client kept being exposed to new team after new team that didn’t read the plan and failed to recognize the communicative intent of the behaviors, and the medical component to the “challenges” the team demanded to be decreased. This calls for TIBA or trauma informed behavior analysis (if the team is not already using it).

So it’s not enough for our clients to learn these skills one time. The people who make up the audience, the environment, must respond enough to maintain them. If I ask for help and you respond no, why would I ask again? Remember the lessons of the family whose school team actually discouraged them from using “saying no” as a goal for their adolescent girl with autism, arguing that they didn’t have the resources to deal with her protesting all day long. Actually, the opposite is more likely to be true—that when our “no” is respected (listened to the first time), its use will be more limited to situations in which the person really “needs” it.

So back to my original questions. How do we raise little ones who are likely to grow up to appreciate and shape the voice of the voiceless, who honor the needs of people in ugly situations, who see the beauty in what others view as broken or beyond repair? How do we insure people will have the internal resources to value what isn’t immediately perceived as “valuable” by the culture? Maybe it starts when they are little, in modeling ways we can accord dignity to the frail, the elderly, the dirty. We cultivate tenderness as we show them we appreciate the spiderweb (AND the spider), the weed and its flower, the worm (thanks, mom and dad, Nicolette Sowder of wilderchild, and my very first client who taught me that not being able to talk is not the same as not having anything to say- click here to learn about Rett Syndrome).

Thanks to mom and dad, I still notice bugs and their beauty. I thought this one was wonderful when I looked closely, so I spent even more time to study and draw him. I thought he became even more beautiful as I continued to look. Maybe you can see his beauty too.

edh

Colorado Potato Beetle by Camille Kolu (c) 2018

P.S. There is so much trauma in our schools today, whether you work with students who are “typically developing/ neurotypical” or those with intellectual, developmental and physical differences. Don’t miss the next course from Cusp Emergence University on trauma informed behavior analysis in the educational setting (complete with CEU’s including one for ethics).

Some references and resources

CuspEmergenceUniversity

Articles on prevalence of assault and ACES in individuals with developmental differences:

https://injuryprevention.bmj.com/content/14/2/87.short

http://www.cfp.ca/content/52/11/1410.short

https://www.acesconnection.com/fileSendAction/fcType/0/fcOid/399727599841302176/filePointer/399727599841302363/fodoid/399727599841302361/ACESandDevelopmentalDisabilitiesSteveMarcal.pdf

Read about Imagine! Smart Homes: https://imaginecolorado.org/services/imagine-smarthomes

Watch Shelly’s story: https://video.xx.fbcdn.net/v/t42.9040-2/51213666_2064787060269873_328394071330521088_n.mp4?_nc_cat=110&efg=eyJybHIiOjMxMSwicmxhIjoxMjA3LCJ2ZW5jb2RlX3RhZyI6InN2ZV9zZCJ9&_nc_ht=video.fads1-1.fna&oh=79aed874369dc8f2ab3a3cc89efdd34c&oe=5C4F807E

Read about the man who developed an app for his brother: https://www.bbc.com/news/av/stories-47001068/how-brotherly-love-led-to-an-app-to-help-thousands-of-autistic-children

https://imaginecolorado.org/

Get the full TIBA (trauma informed behavior analysis series): https://cuspemergence.com/tiba-series/