Author: Barry Morgenstern

Often, when doing a consultation, I’ll hear praise for a particular person about his or her skill in working with a particular individual. People will say things like, “She is great with him” or “He knows him so well.” If you have a person like that, you can probably teach the child more skills and increase the amount of inclusion, and have less problem behavior. In fact, I’ve seen many, many situations where the child is able to do extraordinary things that wouldn’t be possible without the person who is “great with him” (GWH).

While having a person like that on the team has huge advantages, it also has some potential risks. What risks could there be in learning more academic and self-help skills, dealing with less problem behavior, and increasing great social interactions with peers? The problem is the GWH can hide difficulties that often don’t get addressed properly as long as they are there. For example, maybe the child doesn’t speak very clearly, but GWH understands everything he says, so improvement in speech clarity isn’t addressed. Or, GWH knows exactly when he needs a break to prevent problem behaviors, so the child never learns to independently ask for a break.

In all likelihood, the staff who is “great with him” won’t be there forever. Eventually, the child will need to function independently, or at least with different staff people. It is essential that we not let GWH’s cover up issues that are critical for us to address.

On the other hand, when BCBAs are concerned about this problem, they sometimes take the argument to the other extreme. Everyone should be able to work with everyone. We will do cross-training, we will rotate staff every hour, etc. Taken too far, this, too, will reduce progress. It takes time to build relationships, learn all the important details, provide training, communication, and coordination of activities, etc. Having different people work with the child is important, but it is easy to over-do it, and slow progress.

The answer is to understand why the GWH is so effective. If you analyze how the GWH works their “magic,” you get all the advantages of having that person on the team, and still program the skills needed for generalization and maintenance when GWH leaves. For example, if you find out that the GWH understands everything the child says, but few other people are able to do that, speech clarity should be targeted.

Often, a GWH can hide a large number of problems. The answer is not to keep the GWH with the child as long as possible, or conversely, introduce as many novel people as possible. Instead, figure out why the GWH is effective, and then use that knowledge to program for generalization in the future.

Parents, teachers, and other stakeholders are eager for practical information they can use now!  Specifically, they want the answer to the question, “What do I do when he XXX? “What do I do when he screams about doing his homework?” “What do I do at recess when he just walks around the perimeter and doesn’t play with friends?” “What do I do when she lines up items?”

What we say in response to these types of questions is very important for several reasons. First, our response will often largely influence the social validity of the whole intervention. Second, if parents, teachers, or others try our suggestions and they don’t work, they are likely to get discouraged and be resistant in the future. Third, if they take our suggestions and follow them incorrectly, they can make the problem worse than it was before.

Despite how important the answers to these questions are, it isn’t easy to give a clear answer. That’s because of a major conflict in the way behavior change actually works.  Almost all behavioral intervention involves breaking down a big task and teaching it in “baby steps.” For example, if we are working with severe problem behavior, a common first step in the treatment process is teaching a communication response. In most cases, that communication response needs some direct training. That step might take just a few minutes. Then, you proceed to step 2, and on and on, until you have a successful intervention that is practical.

Frequently, when you get the referral for severe problem behavior, the stakeholders expect you to do something about every problem happening – immediately: What do I do in the grocery store, when I drop off at grandma’s house, when washing his hands? From the perspective of the BCBA looking at data on the “baby steps,” things might be going great. Maybe we went through ten baby steps, and everything is going in the right direction. But the person’s life probably isn’t that different yet; the intervention fails the practicality test. We might have some behavior change, but it isn’t effective yet. At this point, we haven’t made a socially significant difference in the child’s life.

There are many helpful actions we can take to improve this situation, including setting clear expectations from the beginning, communicating with stakeholders frequently, and progressing to practical implementation across the day as soon as possible. But one thing that often gets missed is ensuring the stakeholders actually see and understand the step-by-step progress. If intervention happens at school, it is often difficult for parents to observe what’s happening. If intervention happens at home, and parents are working or going shopping during therapy, they don’t see the step-by-step progress that’s happening with the therapists. Sure, progress reports, team meetings, and daily notes might be helpful. But there is no substitute for making sure stakeholders can frequently observe the progress first-hand. Of course, we already know this, but often it can be difficult to make happen.

It can be tough to arrange stakeholder observations for logistical reasons. But logistics are not the sole reason that stakeholders fail to see progress. Sometimes, there are lawyers arguing over how much observation time is appropriate, privacy concerns with other children in schools, organization policy on video, or parents who might be unsatisfied and make critical comments.

COVID-19 almost certainly has many lessons to teach us. Many of us were promoting this idea for years in the “before times,” but it frequently didn’t happen. Now, many families are able to see daily progress since they are receiving all services at home. Sure, it might be uncomfortable when things aren’t going in the desired direction. Sometimes, being uncomfortable is necessary for the Poogi.

Often, we think the biggest opportunities to learn come from formal training. Sure, you might learn something useful at a conference or a workshop. But, although we loathe to admit it, the odds of you being able to return to work and put into practice what you saw at the conference or workshop are low. Usually, you must do a lot of prep work and a lot of follow-up. This might include study, preparation, reading the original research, etc. You should definitely do that, but when Monday morning rolls around and the emergencies start up, it is easy to forget these non-urgent opportunities.

In my view, our biggest opportunities to learn come from the direct feedback we get from our own practice. I learned this from my friend and mentor Alan. Alan isn’t a BCBA, or in the field at all, but he has taught me a lot. He suggests that big opportunities to learn arise when our expectations fail to meet our reality. We implement a behavior change program, organizational behavior management intervention, or other initiative. Of course, we have positive expectations that things will go well. If the intervention rolls out as we expect, it suggests we understood the situation well. But if the situation doesn’t roll out as we expect, there is usually a lot to learn.

If the intervention didn’t achieve the desired results, do we go back and ask, “Why not?” Rarely. But we should. Understanding why an intervention failed leads to big opportunities to learn. Unfortunately, we often just try a different procedure.

Sometimes, the intervention we attempt achieves much better results that we expected. In this case, we might cheer and immediately move on to the next thing. But the fact that the results were so much better than we expected suggests that we did not fully understand the situation. Why was it so much better than expected?

We tend to focus on immediate results. When something isn’t working, we often aren’t that interested in analyzing why we thought it would work, but didn’t. When something works better than we expected, we are too eager to celebrate the success. Anytime we are surprised should be a signal to stop, slow down, and analyze what’s happening. It is a huge opportunity we often miss. Alan teaches how to do this here.

For years, I preached the importance of everyone to be consistent. Now, I’m not so sure it was a good idea. When working with children with problem behavior, typically an assessment is conducted, then the BCBA writes the plan, trains everyone on the plan, and then a day is picked when everyone will implement the plan. Of course, in that type of situation, if people are using different procedures, success is unlikely. Therefore, it is essential that everyone be consistent.

Certainly, that kind of approach can work sometimes. But often, that approach runs into problems. Specifically, three common problems emerge:

Problem 1: In nearly every case, it is not ideal to implement all the procedures at one time. For example, many behavior plans include teaching a communication response so that the child can receive reinforcement in another way besides problem behavior. If a child has problem behavior to gain access to the teacher’s attention, a BCBA might teach the child to say something appropriate like “Can you check my work?”  Now, the teacher might have a whole class of children, and if the child asks too much, it will make the plan impractical. Therefore, eventually the child has to learn that sometimes the teacher will deny the request and you still can’t engage in problem behavior. Usually, those two different lessons–(1) Use communication instead of problem behavior and (2) Communication only works to get what you want some of the time–should be taught separately. If you try to teach them at the same time, success is unlikely.

Problem 2: Idiosyncratic events will distort the team’s focus. For example, if the initial parts of the treatment aren’t done under similar conditions, teams will often lose focus. Today was an assembly, fire drill, grandma was visiting, his brother had friends over, or the neighbor’s dog was barking. Of course, to successfully treat problem behavior, we need to help in a wide variety of situations. But if you don’t focus on the critical aspects of the treatment one step a time, failure is much more likely.

Problem 3: It leads to people getting blamed. When things don’t work, we often don’t consider the most obvious reason the plan was bad or impractical. If you start hearing people say things like, “how can we be expected to be successful when XXX does YYY?” you can be sure you are in trouble. Blaming people for failures is always counterproductive. As BCBAs, we should know better. This causes conflicts between people, mistrust, and general lack of effectiveness.

It usually isn’t critical for everyone to be consistent and do things exactly the same way. Implementing behavior plans in a systematic step-by-step fashion is the procedure of choice. Mom and dad are going to interact differently. The art teacher, para, and principal probably will too. If you plan to try to get everyone to be consistent, failure is much more likely.

Suggested Criteria for the Treatment of Problem Behaviors

I believe that one of the hardest problems in the treatment of problem behaviors is identifying the criteria for success. On the one hand, we want to ensure the long-term success of our clients. That implies we should set very high standards for defining success. On the other hand, should we expect perfection? Don’t typically developing children have a tantrum once in a while? Are we being unreasonable? I’m skeptical of many of the criteria that are frequently used. Many of them are necessary, but not sufficient. In my view, you need to achieve the following seven outcomes in order to demonstrate successful treatment that is likely to make a real difference in a person’s life:

1. The behavior problems have been substantially reduced: OK, maybe it doesn’t have to be perfect, but if we didn’t reduce the behavior problems at all, it is hard to argue that we did very much. In addition, we need to collect these types of data to direct daily treatment decision making. Some research articles define “successful” treatment as a reduction in problem behaviors by a certain percent. As a practitioner, that doesn’t make any sense to me. We know it is possible to dramatically reduce problem behaviors and still have huge problems.

2. Appropriate alternative behaviors have been increased: Sure, it is great that the problem behavior is reduced. But if you haven’t increased appropriate alternative behaviors, it is very hard to see how it would last over time without maintaining the program forever. In addition, no practitioner decides that people doing nothing is an acceptable goal. If all that happened is the adults have been shaped to avoid problems, like the parent who tells his child he doesn’t have to do any homework, most people wouldn’t consider that very successful.

3. The treatment is occurring under practical conditions: Sure, it is probably necessary to treat problem behavior under specialized conditions some of the time. But eventually, we have to return to practical conditions. If the behavior change has only been demonstrated for in 5-15-minute sessions or under very special conditions, you aren’t there yet.

4. The behavior change maintains over time: Everyone is happy that the severe problem behavior has been successfully treated. But the hard part is maintaining the change over time. This is a frequent problem. Who cares if the behavior was substantially reduced, only to come back later?

5. The program has a high level of social validity: It is essential that the stakeholders have high levels of support for the goals, procedures, and outcomes of the program. If not, they are not like provide the necessary support over time. Of course, it is possible to have high social validity with all of the above criteria met, yet still have significant problems.

6. The appropriate alternative behaviors are occurring under natural communities of reinforcement: It is wonderful if we have achieved a high level of success with behavioral intervention. But if the reinforcement doesn’t occur under natural conditions, it is likely a short-term success. No one can maintain a behavior change forever with contrived contingencies. Eventually, it almost always becomes impossible to maintain behavior changes if they don’t occur naturally. I believe the only long-term possibility is natural reinforcement.

7. The person is flexible enough to change their own behavior when the situation changes– As frustrating as it is, sometimes even a natural contingency is not enough. In the real world, things change all the time. If the person can’t change with them, the behavior problems are likely to come back.

Of course, there are some clients with some behavior problems where all of these criteria are not possible with the current state of knowledge in the field. But if you don’t have a good idea of what success looks like, it is hard to Poogi.