Preference and Person-Centered Services

Preference, or choice, is the allocation of responding to one among many alternative responses (Fisher & Mazur, 1997). Changing preferences may yield access to a larger variety of reinforcing items, which may be beneficial, for example, to individuals who have developmental disabilities, and who generally have a narrow array of preferred stimuli or activities that can be used as reinforcers in the learning process (Hanley, Iwata, Roscoe, Thompson & Lindberg, 2003). Changing preferences may also lead to better quality of work life (Green, Reid, Passante & Canipe, 2008), and increase access to work-related “natural reinforcement” (Daniels & Daniels, 2006).

While there is evidence that several procedures effectively change preference, in applied settings it is important to use interventions that will require the least amount of complexity. For example, Hanley et al. (2003a) showed that response-restriction—limiting access to a preferred item below baseline levels—could be used to temporarily affect the preference of three adults with developmental disabilities for vocational and leisure tasks. The activities selected were ones reported to be preferred, available in the home or workshop area, could be placed on a table, and with which the participants could interact independently. Interaction with the activities was measured using 5-s partial interval recording, within a 5-min session. Preference for an activity was measured following four rules that aimed at determining which activity was the one in which a participant would engage for the largest percentage of intervals. Restricting access to the preferred activities led to an increase in engagement with the less preferred ones.

Changes in the way billing is currently done for services provided for adults with intellectual or developmental disabilities (IDD) now recommend a person-centered approach and services provided in the Home and Community-Based Settings (HCBS), which means more integration of the person with IDD into mainstream society. Understanding preferences and ways in which one can assess, and increase preference for one task or decrease it for another can be valuable tools in providing person-centered care that widens the possibility of inclusion and adaptability in novel settings.  Behavior analysts are well equipped to help in developing interventions and program that can lead to more successful job placements, where an individual can have his skills set paired with preferred activities. With a little creativity, a lot can be done.

How do you prepare the people you serve for integration and independence? What roles do preference assessment and programmed preference change take in your practice? Comment below and share your experience with us.

References

Daniels, A., & Daniels, J. (2006). Performance Management: Changing Behavior that Drives Organizational Effectiveness. Atlanta, GA: Performance Management Publications.

Fisher, W. W., & Mazur, J. E. (1997). Basic and applied research on choice responding. Journal of Applied Behavior Analysis, 30, 387-410.

Green, C. W., Reid, D. H., Passante, S., Canipe, V. (2008). Changing less-preferred duties to more-preferred: a potential strategy for improving supervisor work enjoyment. Journal of Organizational Behavior Management, 28, 90-109.

Hanley, G. P., Iwata, B. A., Lindberg, J. S., & Conners, J. (2003). Response-restriction analysis: assessment of activity preferences. Journal of Applied Behavior Analysis, 36, 47-58.

Hanley, G., Iwata, B., Roscoe, E. M., Thompson, R. H., & Lindberg, J. S. (2003). Response- restriction analysis: II. alteration of activity preferences. Journal of Applied Behavior Analysis, 36,  59-76.

Care That Fits Your Needs

When I was a child I loved watching The Jetsons. I often wondered if when I grew up, things would be like they described. As a mother, I have watched the cartoon again with my kids, and felt excited noticing the advances in technology that are present nowadays: phone calls in which you can see the person whom you’re calling (facetime), moving walk ways, and vending machines where you can press a button and get the beverage or snack of your choice.

There were a few episodes which depicted health care. Mostly they showcased machines that could scan your body (MRI?) or a doctor who could see you on a computer screen (telehealth?) . While it seems that they got it right in terms of the technology advances, I think there is still much room to imagine improvements in the way patients are seen, and in their relationship with the providers.

Imagine being able to have all your health needs taken care in the same facility with a group of providers that work as team and can collaborate to offer the best care to you. Imagine, the referral to a behavioral health provider being as simple as walking down the hallway, and having your primary care doctor (PCP) talk to a colleague who is a behavioral health consultant (BHC) working as part of your team. Imagine having your physical health, mental health, and social services needs being addressed at the same time rather than in silos. Imagine that all the providers who work with you respect your opinion, your cultural beliefs, and your decisions about what is important to you in your care. Imagine that as a provider, you have access to all the information you need about a patient, and that collaboration with other specialties and services is seamless. Sound like a fantasy? Well, that is what integrated behavioral health care can offer.

Integrated Behavioral Health Care reduces costs, particularly for patients with complex needs or chronic conditions. Patients with intellectual and developmental disabilities (IDD) make up one of the most complex group of patients, who often need the care of multiple providers. The prevalence of behavioral health disorders is greater for patients with IDD than in the general population. Many times, these patients also have other comorbidities, such as diabetes, and gastrointestinal issues. Traditionally, these patients are seen by several different providers (internist, psychiatrist, podiatrist, nutritionist, speech therapists, behavior specialists) separately, leading to siloed cared, high costs and poor health outcomes.

Behavior Analysts are trained in assessing the many variables that affect an outcome, and in manipulating the environment to address complex situations. Using person-centered behavioral interventions, we teach adaptive replacement behaviors and skills, creating an environment that supports adaptive replacement behaviors and skills development. We design simple, innovative interventions that have contributed to reduced need of restrictive interventions (e.g. restraints, seclusion, intra-muscular medications), longer community tenure, and reduced length of stay in inpatient settings.

We can all do more to help integrate behavior analysis into health care. Here is a little bit about what I do:

The Behavior Web offers consulting packages that assists in the process of delivering integrated behavioral care for individuals with IDD and the providers serving this population:

  • Care Coordination
  • Collocated Care
  • Case Consultation for Behavior Management
  • Individualized Training
  • Workflow training and consultation to optimize communication and productivity

Care Coordination

Protocols that enhance communication among providers and the residential facility, and among providers themselves are developed based on the needs of each facility.

Training is offered so that staff accompanying the individuals to medical appointments know what to report and what to ask. Emphasis is placed on the importance of behavioral signs that may serve as means of communication for the patient, indicating discomfort or a change in condition.

Collocated Care

The Behavior Web professionals are able to conduct behavior assessments, design treatment plans, provide treatment and conduct parent/caregiver trainings to address challenging behaviors through positive behavior supports and strategies.

Options available to the Medical Team, include:

  • Establishing a referral workflow to our team for follow up
  • Incorporation of an “on call” provider
  • Scheduling an on-site provider (full- or part-time)

Case Consultation for Behavior Management

The Behavior Web offers individualized assessment and design of behavior plans that include antecedent interventions, reducing the need for restrictive interventions, leading to safety for patients and staff, and creating opportunities for the learning of adaptive replacement skills.

Individualized Training

The Behavior Web offers individualized training in behavior assessment and behavior management, person-centered planning and effective treatment planning which can be offered in vivo or on line.

You will be able to track your staff’s attendance and performance on all courses you decide are best for your team.

Workflow Training and Consultation

By understanding all the steps involved in providing care to your patients, and the touch points needed with other providers and staff in the clinic, we help design workflows that improve communication, productivity and reduce wait time.

How about you? How do you use behavior analysis to transform healthcare?

 

Knock, Knock: Are You Home?

Behavior analysts pride themselves in the understanding of behavior and its interactions with the environment. Once you understand the world through the behavior analysis lenses, you can’t help but to explain all behavior—individual, group, or organizational—through it. (for an interesting take on group behavior related to a recent fad, read this post). It is a fact that humans nowadays spend long hours connect to the internet, through various devices (computer, phones, tablets, and now even watches); however, our practice of service delivery seems stuck in the 80’s. 

ABA therapy has traditionally been delivered at home. Usually, an experienced therapist goes to the child’s home, interviews the parents, assesses the child, observes his or her behavior at home. Then a treatment plan is designed and delivered by behavior technicians with regular supervision from the behavior analyst who designed the plan. Variations of this model include doing all activities described above at a clinic or treatment center. This hasn’t changed much since Lovaas’ days.

The advent of telemedicine brings new opportunities to expand access to behavior therapy, and behavior analysts. There are still some areas in the United States, and many around the world, where access to behavior analysts is not easy. Taking advantage of a behavior already in people’s repertoire (using the internet), with high association to positive reinforcement, would make it possible to extend the reach of ABA to rural populations and other areas where finding a BCBA is not easy.

There are several studies which support the use of ABA in telemedicine or telehealth. An EBSCOhost search with the terms “telemedicine and autism” yielded 338 results. For example, Lindgren, Wacker, Suess, Schieltz, Pelzel, Kopelman, Lee, Romani, and Waldron (2016) compared three delivery models (in-home therapy, telehealth at the clinic, and telehealth at home) with an interest in the differences in outcomes and cost in the treatment of challenging behavior through parent training. With a sample of 94 children, they found that the mean percentage of reduction of the target behavior was >90% for all three groups. While treatment acceptability was high for all three groups, the costs associated with telehealth at home were substantially lower.

A little creativity with the use of the technology available nowadays, can really improve access to and integration of ABA into a great variety of setting, and models; and I know there are few professionals more creative than behavior analysts. Let’s pay heed to this opportunity and bring ABA to the world.

Behavior Analysts and Healthcare Transformation

The healthcare landscaping is changing, and integrated care is the goal. How can behavior analysts fit into this new model? Many states now offer ABA services through health insurance; with that, the demand for ABA services and the need for integration of what we do to primary care practice will only increase. Behavior analysts need to be ready to be part of an interdisciplinary team, and to be able to participate in discussions and collaborate in treatment planning with other healthcare professionals, who most of the time are unfamiliar with behavior analysis.

Fully integrated behavioral health care involves having a team of providers working together, in the same facility, using the same EMR (Electronic Medical Record) system, who actively seek solutions and treatment approaches together. For the most part, behavior analysts have traditionally worked by themselves, delivering treatment in the client’s home, with occasional interactions with other providers—this is not an easy transition.

Behavior analysts are trained in looking at the context of a presenting situation, and analyzing the various ways in which variables interact to create an effect—we can bring a lot of value to this model, being in a perfect position to participate, as an assessor, a trainer (for staff, patients, and caregivers) and an interventionist. Some of the obstacles for this integration are learning new skills, such as medical literacy, and learning to collaborate with other providers frequently, such that a shared treatment goal can be established and achieved.

There is no formal training offered by graduate schools in behavior analysis that prepares the behavior analyst for this new role. It is incumbent on the supervisors, trainees, and curious behavior analysts to learn more about how to make themselves an essential part of the integrated behavioral healthcare model. I have always been a firm believer that ABA can improve the quality of life of many people. This is the perfect opportunity to expand the reach of behavior analysis!  To learn more, visit some of the websites below:

https://www.thenationalcouncil.org/

http://thenadd.org/

https://www.samhsa.gov/health-care-health-systems-integration

It Is Behavior Science, Not Magic

The CEO of the hospital where I used to work frequently said “I love watching you do your magic, Lili”. I often replied “It’s not magic, it’s science”, and he would look at me in disbelief and say “I think it’s you.” As flattering as the thought of being special was, I knew there nothing I was doing that a well-trained and willing behavior scientist would not be able to do.  magic-1688274_1920

And then, life happened.

I met cases in which I knew what should be done, I knew how to do it, but doing it involved a tremendous amount of energy and resources which I couldn’t accomplish by myself. I caught myself thinking that “I should be able to do it anyway”, or that “not being able to fix it would somehow make me less of a behavior analyst”. Well, Lili, it’s behavior analysis, not magic.

When we tackle a case, while people may think we will wave a wand and make everything better, the reality is that it involves a lot of work. We need to assess the target behaviors and how the environment affects them, and in the process we become part of those environmental variables affecting behavior. Then, we need to engage in the hard work of modifying those variables.  I think this definition of resistance alludes to what every behavior analyst faces daily at work: “resistance force is the force which an effort force must overcome in order to do work on an object”.

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In planning a behavior modification, we often have to take how effort will affect the strength of a reinforcer. How often do we really consider that for ourselves? There is only so much effort in which one can engage without coming in contact with reinforcers. If the biggest reinforcer you receive through work is watching progress (Gotta love those sexy graphs!), a difficult case may reduce substantially the opportunity to come in contact with those reinforcers. We may notice in ourselves, behavior related to ratio strain, extinction, punishment, etc. So what would you do, if you were the one you were treating?

When one of the individuals with whom we work, is displaying the negative signs of ration strain, extinction, or punishment, we often seek to reduce effort or increase the size of the reinforcer, right? So when we are faced with such cases, we can look to reduce the effort and increase the size of the reinforcer, by collaborating with other professionals, including professionals from other disciplines. It is not magic! You can’t do it alone.

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The Behavior Web offers a forum where behavior analysts can come together and talk about the challenges they face in their day-to-day work. We meet online weekly, and it is completely free. You can sign up for next week’s meeting here.

What Makes A Great Manager?

manager-454866_1920There are many qualities to a good manager: ability to deliver positive reinforcement, establish attainable and challenging goals, ability to engage and motivate, and ability to create a clear vision of the target state are a few that can readily be named. Today, I would like to discuss one particular sign of a good manager, the ability to build sustainability beyond his or her presence.

It is said that a good manager run a “tight ship”, meaning they have a good grasp on what happens on their department at all times, and they are involved in such a way that leads everyone to do what they have to do. But what happens if that manager is absent for a long period of time, or if she or he leaves? Will the proverbial ship reach its destination?

A good manager plans for absence. We all want to grow, so we need to plan what will happen to our department once we move on. A sign of a great manager is the way the department stands once that manager is no longer there. What systems have been created that ensure that things will get done when they need to get done, in the way the need to get done? What monitoring mechanisms have been created that will ensure that any fall out is captured? ship-1632613_1920

Being a good manager requires that you have a clear vision of the “mission” of your department, and that you have a clear idea of the steps needed to achieve that mission. Next, you will need to think about how you are going to implement those steps? What is the first module of behavior change that needs to happen? All along, you need to be measuring the essential behaviors and outcomes, in order to know for sure that you are in the right path.

That is why not everyone can be a great manager. It takes a lot of attention to detail, and diligence to be able to understand these shaping steps, and to carry them out. A good manager is recognized through day-to-day operations; a great manager can be recognized in his or her absence. What will your legacy be?

So Your Direct Care Worker Is… Lazy?

It is true that one of the greatest challenges we face as behavior analysts is the commitment of those delivering the services we design. Whether you work in private therapy with kids with developmental disabilities, or at a large service delivery organization, chances are that the person designing the behavior programs and the person delivering the program is not the same. In fact, many times one person creates the plan and several people are responsible for its delivery. Many times, the person delivering the service does not have training in behavior analysis—teachers, aides, patient technicians, nurses, etc.—and at times they outright tell you that ABA is a waste of time.

sloth-1502299_1280This week, I heard someone complaining that their direct care worker was “just lazy”, and that is the reason the behavior plan did not work. I asked her to tell me more, and she described how inefficient that worker was in collecting data, proudly showing the discrepancies on the graphs of the data she collected and the data the direct care worker collected: “You see, he is just entering any number, he can’t be bothered with actually taking the data.” Humm… Perhaps the difference is due to the fact that you know how to collect the data, and the direct care worker doesn’t? Perhaps you understand the reason why data needs to be collect, but the direct care worker thinks it’s just extra work? Perhaps it is hard for the direct care worker to collect data with all the other demands of his job?

The reasons why that worker could vary tremendously, but what about laziness? Dictionary.com defines the term lazy as “averse or disinclined to work”. So, now that we have taken the subjectivity out of the term, and defined like this, the solution to the problem of a lazy worker becomes crystal clear: it is an issue of motivation. We, as the people who know the science of behavior modification are actually the ones who understand how to use is principles to change performance, even that of a “lazy worker”.

rope-1469244_1280When we create a behavior modification program, we are actually treating the web of behaviors that are related to the target behavior. We are treating the behavior of the client, and the behavior of the personnel delivering the program. Yes, it can be very frustrating to work with people who do not understand ABA. It can also be extremely rewarding and exciting! When we are faced with a worker who presents challenges, let’s use that opportunity to expand out net to web of behaviors around us, and let’s do that one little bit to help change the world.

Let us know of your experience with difficult workers. How did you address it? What worked? What did not work? You may also what to read Why Some Behavioral Interventions Don’t Seem To Work for another interesting take on this issue.

Diversity and Behavior Analysis

Behavior analysis is widely used to teach atypical individuals (people with developmental disabilities, people with mental illness, people with learning disabilities) to behave as typical individuals. One can argue that is building a repertoire of socially accepted adaptive and functional behavior. This morning, I caught myself wondering: in a world so diverse, and with so many different cultures what is really adaptive and functional, and how is diversity represented in ABA practice?system-927147__180

I have not conducted any research on this subject (I leave that to the academics), so I am only describing what has been my experience, which is probably somewhat biased, being that I am Latina, first generation in the United States. So take what I am writing with a grain of salt and comment below to let us know about your own experiences.

The issue of diversity can be thought through different paths: a) how diverse are the behaviors we teach, b) how diverse are those served by ABA, and c) how diverse are ABA providers. Let’s talk about each of these items separately.

Applied behavior analysis and the methodologies derived from it (e.g. social skills training, discrete trial training, etc.) are suited to teach a variety of behaviors. A quick search through JABA (Journal of Applied Behavior Analysis) will bring you to articles addressing behaviors ranging from toilet training to delusional speech, and it will include a variety of settings (hospitals, schools, home, playground, and work). I would say that we are pretty diverse in the possibilities we can offer to those seeking help through ABA.

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The same search on JABA will yield results that also include men, women, children, employees, supervisors, people with developmental disabilities, typical students, people with mental illness, people looking to lose weight, and more. While a search through JABA may lead you to believe that we serve a very diverse population, the reality is that like most articles on JABA are related to people with developmental disabilities, so is our practice.

Few of us have worked with a client who did not have developmental disability. Interestingly, when I was in grad school, I remember many of my colleagues—all of us fascinated with the science of behavior—being curious about other areas of applications (e.g. mental health, gambling, performance improvement, law enforcement, correctional facilities). In experience, students fell in love with the science, and were excited about the possibilities that it could bring to the world at large, but were somewhat discouraged by the prospect of a career path limited mostly to working with autism.

thinkific_courseimagesa-003You may know different in the area that you work, but in my 10 years of experience working with ABA I know only two first generation Latina immigrants who hold a BCBA. In the same 10 years, I have met only one African American BCBA. Most ABA practitioners are women, Caucasian women. When it comes to diversity of providers, there is a lot of room for improvement.

In my experience, I have worked with people with developmental disabilities, people with severe mental illness, with organizational change, and I have taught university classes. My clients reflected the diversity in the United States—many were speakers of other languages, and were children of immigrants. To better serve this diverse population, it is important to understand the richness of their background; it is important to be able to understand their values (since they will affect the motivating operations in our work), and what is important to them.

We have work to do. It is up to us to enhance training for behavior analysts so that cultural issues can be incorporated in a person-centered way. It is up to us to enhance access to behavior analysis services, so that a wider range of the population can benefit from its teachings. It is up to us.

Who Are We Training?

 

changeAs behavior analysts we are in the business of changing behavior. Usually we are hired to train a particular individual (e.g. a person with mental illness, a child with developmental disabilities, a leader who needs coaching) or a group of people (e.g. staff members, teachers), and we concentrate our efforts on that client’s target behaviors—what he is doing too much of, what she is doing too little of, what they need to learn.

We then, start thinking of all the contingencies that affect the target behaviors. What kind of reinforcement scheduleweb would work best? Perhaps we need to put an escape maintained behavior on extinction, or maybe we need to
come up with a shaping procedure; the options are endless. But who are we really training when we come up with a behavior program? While we may think we are training the client, I’ll say we are training the environment.

Behavior is a function of its interaction with the environment. Any behavior present in anybody’s repertoire exists in an environment that supports its presence, or, in other words, reinforces it. We know that it is impossible to change behavior without changing the environment. Yet, many times we consider the behavior of the client and what needs to happen in the environment in order to support the client’s behavior change, and forget to consider the impact of that change in the environment as a whole.

board-953155_640When we ask a manager to praise behaviors that lead to target outcomes, and that manager says “I don’t have time to go around talking to people”, we may be quick to think “Well, then you really don’t want to achieve the results.” Did we really take a look at the demands faced by this manager? Is there any other way that we could shape his praising behavior and gradually increase its frequency, rather than starting at that level that is ideal, and we know is going to offer the fastest most noticeable results?

When teachers and parents refuse to collect data, do we look at the contingencies surrounding the behavior change we are asking of the parent or teacher, before labeling them as “uninterested or non-committing”? When we
are faced with a though case, for which we have “tried everything and nothing works”, have we looked at the web of interrelated behaviors we are trying to change? hand-1030569_640

We teach the environment.
If a behavior change program—at an organization, at private practice, at school, at home—is to be successful, we need to plan how to support environmental changes that will in turn support target behavior change. By considering the environment your real client, you will be able to shape behavior change that is long lasting, sustainable and successful.

What’s In Your Language?

globe-110775_640Behavior analysts in general love technical language. I am guilty as charged—I love talking about technical terms, and once I even wrote a paper reviewing how behavior analysts use the term prompt (you can check it here), but I want to know about your everyday language. Have you thought about the implications of your language on patient treatment, stigma, and ultimately how the world perceives ABA?

Words like “appropriate”, “compliance”, “off-task”, and “nicely” to name a few, are abundant in a behavior analyst’s verbal repertoire and even make its way to peer-reviewed literature, solidifying its sanction in our practice. Have you thought about what they mean, and what they indicate? Control. Ultimately, these are words of control.

Behavioral health care in recent years has shifted towards a recovery-oriented approach (for more info, check here).  water-lily-1533183_640That means that the focus of treatment of people with mental illness has moved towards building more independence and community re-integration. Managed care organizations are interested in treatment plans that promote recovery and self-reliance, and they expect to see recovery-oriented language reflected in the assessment and treatment goals.

When working with people with disabilities (mental health, developmental disabilities, physical disability) our goal is to develop independence, not compliance. Independence includes assertiveness, it includes the ability to say no. When we teach compliance, what are we really teaching? Obedience? michelangelo-71282_640

The Professional and Ethical Compliance Code for Behavior Analysts mentions the word “appropriate” 36 times (!), and the term “person-centered” 0 times.  Only recently health insurance companies started to offer coverage for ABA services, and it is imperative that we are able to communicate in that same language as other behavioral health providers.

Behavior analysis is suited to promote recovery and community re-integration better than other treatment approaches, because we understand the ways in which the environment intertwines with an individual’s condition. Our language needs to start matching what our practice has done for years: the support of the individual and the families in the recovery process.

Check out these resources for more information on person-centered treatment and recovery-oriented language:

Recovery-oriented Language Guide:

http://mob.mhcc.org.au/media/5902/mhcc-recovery-oriented-language-guide-final-web.pdf

Practice Guidelines for Recovery-oriented Behavioral Health Care:

http://medicine.yale.edu/psychiatry/prch/tools/practice_guidelines.aspx

Guide to Developing Goals and Interventions:

https://www.omh.ny.gov/omhweb/pros/Person_Centered_Workbook/Quick_Guide_to_Developing_Goals.pdf