Author: Barry Morgenstern

One Year Anniversary Post

Since I began writing this blog, several people have asked me if a particular post is about them. Carly admitted that her song was a composite of several people. I thought it was worth addressing how I refer to other people on my blog.

Here are the basic rules I use:

Sometimes what I’m describing is a composite of different situations that I’ve seen again and again, and typically don’t represent a specific person. In that case, I’ll say things like, “Let’s say I’m working a child who…”

If I’m talking about a specific case, I typically say so as in “One time I was working with a child who…” Of course, memory is fallible, and sometimes I’m writing about events years or decades later, so some of the details are probably wrong. Also, I disguise some of the details to protect both confidentiality and the guilty. In spite of this, I strongly believe the message is accurate.

But mostly, I’m talking about my own mistakes. I have frequently given a presentation titled, “I’ve Made All the Mistakes So You Don’t Have To.” The old saying goes that a smart person learns from his own mistakes, but a wise person learns from the mistakes of others.” I consider myself smart – but not very wise. Typically, until I try it and fail, I tend not to learn the lesson.

 

In our field, it isn’t particularly easy to be wise. Sure, we have lots of training, workshops, journal articles, and conferences. But mostly, those discuss successes. There is very little discussion of failed cases and the reasons behind the failed cases. There is even a formal name for this bias – the file drawer effect. Successful cases get published, while failures are often hidden. I see that as my opportunity to contribute. We now have thousands and thousands of new BCBAs. My sincere hope is that these smart people become a bit wiser by reading the blog.

The federal government has implemented a poorly designed pay-for-performance system in health care. Specifically, the government set standards for patient outcomes that are directly tied to Medicare funding. Also, the ratings are very important for the hospitals’ reputation and standing in the community. As a result, hospitals started throwing out donated organs that weren’t perfect. They began refusing to operate on severely ill patients. Because if the hospital were to take those types of risks, their success rate would decrease, and so might their government funding. These contingencies put hospitals in an impossible situation. Doing the right thing could potentially hurt the hospitals’ ratings, reputation, and income.

Although this phenomenon is not widely recognized by BCBAs, there is a lot of research on this topic. A few examples are this book, or another recent one, or in the field of economics. In my view, they are worth studying because similar unintended outcomes frequently occur when BCBAs attempt to implement OBM-type systems, although not as dramatically as in hospitals. On this blog, I’ve talked about this problem in several areas like:

• Teaching staff to accept feedback appropriately,
• Measuring the number of trials conducted daily,
• The use of assessment devices.

I’ve attended many trainings and read lots of books and articles on organizational behavior management (OBM.) The concepts seem so easy to understand; anyone should be able to do it. Yet, if you look into the details of how OBM is implemented in many organizations, it often leads to unexpected negative outcomes. The problem is that these negative outcomes aren’t usually captured in the measurement system, so everyone is celebrating a failed program that looks successful.

One simple question every BCBA should ask before implementing a new OBM system:

Is there any way that this measure can be improved while doing something that is not in the best interest of the client?

If so, we should either:

(a) Eliminate that measurement, or

(b) Add other measurements that ensure that the negative effect won’t happen.

*The title is a quote from Eli Goldratt – author of The Goal

I have previously discussed personal finance for individual BCBAs. Today, I’m discussing financial management for organizations. Many programs often emphasize in their value statements that they do not focus on money or profit. Instead, they focus on providing the highest quality care possible. When there is a conflict between providing high quality care and costs, the highest quality care should always win. This is a marked contrast from other organizations that serve individuals with disabilities who focus on achieving the largest profits possible. We all know organizations like this are out there, but of course none of them advertise their profit maximization philosophy. If they did, it would almost certainly reduce profits; since parents, schools, staff, and other stakeholders would likely rebel.

There are no organizations that have unlimited financial resources; organizations that never have to make choices about spending do not exist.  No matter how big the organization, no matter how much private equity they have, no matter how big their endowment, they must decide how much money to spend on each priority and what they will not spend money on. There are always more possibilities than available resources. These choices show up in things like staff salaries, the quality of the health insurance plan, the type, location, and quality of office space, resources spent on program materials, and so on.

Organizations can say that quality always comes first. They may even believe it and live this value on a day-to-day in their decisions–as they should. But when financial difficulties arise, cuts have to be made. If you are in financial trouble and don’t make changes, eventually the organization will not exist. But cuts often have a major negative impact on quality. I’ve seen this several times over the years, and imagine in this time of COVID-19, many organizations are experiencing this phenomenon.

What’s the lesson? Putting the highest quality care at the top of the list of your organizations priorities is exactly the right approach. Everyone who cares about the lives of individuals with disabilities should seek to work for an organization where this is a deeply held value. But everyone should also realize that money is an absolutely necessary condition of high-quality care. If you can’t afford to pay staff a competitive salary or purchase appropriate program materials, quality is sure to go out the window quickly.

The choice should always be to focus on high quality, not profit. Then realize that if you want to maintain high quality now as well as in the future, you better make absolutely sure you have the financial resources to live that value. High quality programs do not exist without financial resources.

Most children develop some early learning skills with virtually no effort on the part of the parents. Some of these skills are absolutely critical for the child’s development.  For example, at about 8 months of age, children start imitating others. Imitation is absolutely critical for learning social skills, language skills, motor skills, and cognitive skills; development is significantly impaired without imitation.

As BCBAs, we sometimes work with learners who have not acquired imitations skills naturally. Fortunately, our research literature has taught us that most of these children can be taught imitation skills, and that the imitation skills can be used to help the child learn a variety of other types of skills. Unfortunately, I see a common mistake in the teaching of these skills that often delays the process significantly. Why? Poorly designed measurement procedures lead to poorly designed treatments — A common theme on this blog.

Often, BCBAs use the same measurement procedure for all of their programs: progress is measured by number of objectives mastered along with mastery criteria. For example, for three consecutive sessions, the student demonstrates the skill with 90% accuracy, and with two different people. Now, that might be a reasonable process if you are teaching the child something like learning a new word, letters, numbers, colors, or shapes. But when applied to a skill like imitation, things are likely to go wrong.

Why? If you teach the child a new word, you want them to remember it. If the child learns the words juice, shoe, and ball, hopefully, he or she doesn’t forget the words the next week. You want to build on skills like that and teach more words. So, focusing on the number of words mastered is reasonable.

But when you are teaching imitation, there shouldn’t be any concerns about whether the child remembers the previous examples taught. The goal is not to teach something like “arms up,” “clap hands,” or “stomp foot.” The goal is for the child to get the concept of imitation. No matter what we do, the child makes a reasonable attempt at imitation—Damn, is that teapot motion tricky!

We know from the research literature that some children require many, many examples to acquire imitation. Sometimes hundreds of examples. What often happens is a program will spend huge amounts of time focusing on trying to teach the child to learn the difference between the same three examples. In my view, that is an enormous waste of time. It would be much better to simply give novel examples. Each time the child learns one, introduce a new one. To measure progress, record how many trials it took to acquire a new imitation skill rather than focusing on the accuracy. Don’t worry about whether he or she remembers it the next day. This is a much better way to judge progress for this type of skill. When the child starts getting novel examples correct, you’ve done it! That’s the goal. Now, you can probably go back to any of the old examples, and the child will be able to imitate it. Also, you’ll probably be able to use this newly acquired skill to teach other skills.

The same logic can be applied to many early learning programs that have similar criteria. The most common place where I think this change can move things much quicker is the following two types of skills:

Imitation of all types (e.g., actions, actions with objects, gross motor, fine motor, vocal, from videos, complex sequences, peer play, etc)

Matching of all types (e.g., identical objects, non-identical objects, pictures, pictures to objects, objects to pictures, colors, shapes, etc.)

A Follow-up on Teaching Children with Autism to Talk About Things Happening Inside Themselves

I have often had what I think is a great new idea for research, treatment, or other aspect of practice. Then, I start to dig into the scientific literature and determine what is known about the topic. But once I start to dig, I frequently find that my idea has already been taken, extensively discussed, researched, and evaluated. What’s going on?

This is such a common occurrence that I developed a hypothesis that might explain this phenomenon. My premise–people are going back in time, stealing my ideas, and publishing them before I have a chance to do so. But as it turns out, people coming up with similar ideas in scientific and innovative fields is very common, and there is a much more plausible hypothesis to explain this phenomenon–the “Adjacent Possible.”  The adjacent possible hypothesis states that in most fields, new ideas come from possible new combinations at the current cutting edge.

Therefore, my friend Katie and her students probably did not travel through time to steal my idea on how to teach children with autism to talk about private events. They did years of work to publish a great paper on this topic, while I just spend an hour or two on my blog. It may seem like an amazing coincidence that the procedures are nearly identical and were published at nearly the same time. But in science, this happens all the time. It just so happens that teaching children with autism to talk about private events is a common problem in the field, so it makes sense that multiple people would be thinking about it.

In the old days, some researchers hid their program write-ups and made them confidential. Frequently, they refused to share these write-ups; it was a big challenge to locate material as simple as prompting and fading procedures for teaching skills like imitation or matching. Often, these would be printed with warnings about who could and could not use the plans. Thankfully, those days are mostly behind us. Sharing ideas widely, with many people working on the adjacent possible, leads to Poogi for all of us.