Author: Barry Morgenstern

One of my consulting cases was for a child at a public school with severe behavior problems. I typically consulted with the school about once a week. The behaviors were largely well-controlled, but we still had extreme problems that occurred rarely. Therefore, the school team formed an emergency response team. This team included several people who would always have a walkie and be on-call in the case of an emergency.

One day, I walked into the school just as the emergency response team was being called. But when the school secretary (who apparently did not remember my name) saw me, she called it off and said “don’t worry—the man in blue is here.”  I then went to assist with the emergency that was occurring.

I am often the person that gets called in an emergency situation. Although as I get older, this is less and less likely to be me. I suspect we have a potential problem in that there are hidden reinforcers to the people who are called to handle emergencies. Handling an emergency involves breaking of the routine, novel problem solving, people deferring to the expert, a feeling of accomplishment, and often thanks from grateful people. These reinforcers can shape your behavior in insidious ways. Most importantly, you might be spending too much time on emergencies and not enough time teaching the appropriate alternative behaviors that will meet a natural contingency that will make a difference in the long run.

I recently read the book Upstream. He discusses one of the issues in preventing problems from occurring is that we celebrate the lifeguard who saves a drowning victim, but not the swim teacher who prevents someone from drowning in the first place.

Certainly, in most organizations there are huge rewards for the people who are called to handle the emergency situations. That’s appropriate. But I suspect we probably don’t do enough for the staff in the preschool who work daily with a child to teach mands and build tolerance levels that prevent these extreme problems in the first place. It’s a very tricky problem as there are certainly ways to prevent problems that are not in the child’s best interest.

 

One of the most common reasons for doing a comprehensive skills assessment is the fear that if we select target behaviors without one, we might be missing something. Although these assessments can take a lot of time, we believe they are essential. What if we don’t include something in the IEP or Insurance Treatment Plan that is crucial for the child’s future?

I was thoroughly convinced by the logic of this necessity too, until my daughter wrote the following story when she was around nine or ten years old:

Red and Green

By Clara Morgenstern

Once in Louisiana, there was a lady who thought that red is green and green is red. So, when she was driving and there was a red light, she thought it was green and went. When there was a green light, she thought it was red and stopped. But if someone was crossing the street she didn’t go. She had a few other tricks that prevented accidents. But even so she got pulled over by the police and honked at.

So, one day the state police had finally had enough and sent an officer to talk to her parents. After an interview the office had contacted the lady’s old preschool which fortunately was still in business. The director looked at her 42-year-old schedule and concluded that she had been out sick the day the other kids learned their colors. She had never made up the work. So the officer showed up at her house and said, “Ma’am, I think it is time for you to come with me.”

He took her back to preschool where she learned her colors and what all the fuss was about. She even got her old space at circle time, her old cubby, and her old name card. She also met sons and daughters of people she went to preschool with. Now she knows the difference between red and green.

© Clara Morgenstern Used with Permission

Here is a link to the original.

Real-world observation is the best way to determine what is essential. The reason why I’m no longer so concerned about comprehensive assessments is the real world (if you are paying attention!) will teach you what is critical and what isn’t. The reason Red and Green is funny is that it can’t possibly happen. Of course, someone would have figured out that the woman in the story mixed up red and green way before she learned how to drive.

Of course, a comprehensive skills assessment is necessary and appropriate under certain conditions. For example, a child is struggling in math class, and we suspect it is because prerequisite skills are missing. Or a child is struggling to make friends, but we aren’t sure what social skills might be missing. The key is that the cue to do the comprehensive assessment comes from a real-world problem. I don’t think comprehensive skills assessments should be a routine procedure to select target behaviors for an IEP or Treatment Plan. You can teach many, many skills. But if they don’t meet a natural contingency, they are unlikely to maintain anyway.

Many BCBAs spend an enormous amount of time in their cars. This seems like such a waste of time. It leads to complaints like “I spend more time in my car than actually working with kids;” “It is hard to focus because my phone is blowing up all the time with questions, schedule changes, and emergencies;” “It is so stressful when an emergency occurs and I’m an hour away.” In these situations, it is easy to dream about how nice it would be to work in a school or clinic where all the kids would be right there! I’d work with one student from 9-10, the next student from 10-11. Maybe there’d even be time for a real lunch!

On the flip side, many BCBAs who work in schools or clinics are sick of all the interruptions. “There are too many interruptions here. As soon as I sit down to work, five people come in with a question that will just take a minute. I’m going home or to Starbucks to work.” Due to the constant flow of interruptions, it is easy work 10-12 hours and feel like you got nothing done.

So, when all the kids we are working with are spread out, often we think it would be better if they were all together. When all the kids we are working with are together, often we think it would be better if they were spread out. What’s going on here?

I wrote the above before the current situation where many of us are transitioning into remote consultation. Which has its own set of huge benefits and drawbacks.

Many of us have problems with organizational skills. Sure, improvement in organizational skills or creating systems can definitely be helpful. But I don’t think it will solve the problems described above.

The problem is that frequently we are not talking to our staff nearly enough. Talking to your staff regularly will decrease the chance they will interrupt with questions, prevent emergencies from occurring, and increase the chance they will know how to handle emergencies when they happen. I know, I know, the insurance company doesn’t pay for staff meetings. You still have to do it though. If you don’t, quality will suffer.

Our professional literature has emphasized the importance of focusing on natural contingencies for over 50 years. A natural contingency occurs spontaneously without modifying the environment, and serves to maintain the target behavior after the program is over. If we don’t focus on establishing natural contingencies as our end goal, we should expect that eventually the program will not last in the long run. Although I don’t have data, it seems very clear that many applied behavior analysts develop programs that do not focus on establishing natural contingencies. Why? I believe it is a behavior trap.

A behavior trap is a situation where it is relatively easy to engage in the entry behavior, but once you begin, you enter the trap, which changes many behaviors and is very hard to escape. These “traps” can cause both beneficial and harmful behavior changes.

For example, going to college is a common behavior trap. It is relatively easy to apply to college. But once you start, it will produce numerous behavior changes. It often leads to many beneficial behavior changes like developing career skills, making life-long friends, and learning to be independent. It often can yield harmful changes too, like binge drinking and taking on too much debt.

Life is filled with behavior traps.  Some examples include getting a job, joining a church, or even buying a Netflix subscription.

I believe BCBAs are frequently in a behavior trap that prevents many of us from focusing on natural contingencies. First, we get a referral problem – say severe problem behavior, academic difficulties, toileting, or feeding. It is often possible for us to produce huge benefits to the client in a fairly short period of time. That’s a relatively easy entrance response. But the short-term successes trap us into not focusing on the long-term goal of maintaining behavior through natural contingencies.

For example, let’s say a child is referred for self-injurious behavior so dangerous that the child is causing tissue damage to his head. After a few months, self-injurious behavior has been reduced to zero levels. The data on the referral problem look great! The parents are happy! The teachers are thrilled! The funding source is very satisfied! Even the advocates and lawyers are truly appreciative. Everyone is looking at what’s next. He needs to spend more time interacting with peers. We need to get him caught up in academics. He makes loud noises when walking in the hallway, etc. etc.

What usually happens? We make enormous gains in the new referral problems, too. This is highly reinforcing to us (the BCBAs). We are getting huge amounts of positive reinforcement from parents, staff, teachers, and others. We love this job! That’s the behavior trap. Those results all seem positive and everyone is happy, so what’s the problem? Sometimes nothing, the child moves on to make friends independently and go to school without assistance.

In many cases though, there is a big problem. These behavior changes are usually not meeting a natural contingency despite the fact things might look great for a very long time, sometimes even years. But these changes require us to maintain them. This leads to all sorts of negative effects:

• Sometimes any new person who works with the child needs a lot of training on his or her individual plans before they can work with the child successfully.
• Sometimes it is very hard to handle situations when a staff person is out sick.
• Sometimes there is little generalization to the home setting.
• Sometimes, since there are so many things to maintain, small (and large) emergencies frequently pop up. The BCBA spends more and more time fire-fighting.
• Sometimes there is a never-ending list of new referral problems with the same child. The list just keeps growing.
• Sometimes it is impossible to change to a new BCBA (But you know him so well!)
• Often, during life transitions there are huge problems to solve (e.g., starting preschool, kindergarten, middle school, high school, camp, moving into a new house, new teacher, new medical procedures, or any of a thousand others).
• Often, it is easy for the BCBA to become overextended and start to burn out.
• Eventually, there is almost always a reduction in services as either the child has done so well, it is judged the child doesn’t need the intensive services, or the child no longer meets the eligibility for funding. At that point, the amount of regression can be shocking. Most of us expect it, but are still stunned by the extent of it. I’ve seen it numerous times.

Is there an easy solution? No, I don’t think so. The field would have solved this problem by now. But I do think it is helpful for us to be aware of the problem. As much as possible, remind yourself if you don’t have the time to do the work needed to obtain generalization and maintenance of the behavior changes, probably you would be better off not starting the behavior change program in the first place.

Sometimes, what a parent, teacher, or other stakeholder is most concerned about is a behavior that only occurs very rarely. Maybe the child engages in dangerous aggression, toileting accidents, or refusing to go to school. Under normal circumstances these types of referral problems might involve routine assessment and treatment procedures. But if these problems occur at a very low rate – say 1X per month–they become huge challenges for the assessment and treatment process.

First, it will usually be impossible for the BCBA to observe what is causing the problem. The odds of the problem happening during a session are remote. We can’t really work on problems we can’t see. Second, even if you are lucky enough to observe the problem, it often is very unclear how you might approach treatment. Normally, the initial step in treatment would be to figure out why the problem is occurring (i.e., functional assessment). While this may be possible with infrequent behaviors, it is very difficult. Third, it is very difficult to monitor progress. If you attempt an intervention, you will have to wait months to determine if the intervention is having an effect. What to do?

In this type of situation, the key is to dig a bit deeper into the specifics to find a way to work on the referral concern without all the negatives described above.

Some examples:

• If the child engages in severe aggression only rarely, are there other problem behaviors? Maybe he complains sometimes? Or yells sometimes? In all likelihood those behaviors are occurring for similar reasons. If you address some of the other, more common problem behaviors, it likely will have a big impact on the aggression too.
• If the child almost always uses the toilet well, but rarely she has accidents: Why? Maybe the adults always remind her to use the bathroom and accidents only occur when adults forget to provide a reminder. Or, she waits until the last second and rushes to go, and occasionally doesn’t make it in time.
• If the child usually goes to school without an issue and only rarely refuses. Why? Maybe he sleeps poorly, and only when extremely sleep deprived is school refusal a problem.
• If the problem is rare because it only occurs during unusual conditions (e.g., fire drill), then can you create additional opportunities to practice (e.g., audio recording of the alarm)?

Every situation might be different. But if you dig into the specifics of the situation, usually (certainly not always!) a practical way to address the referral complaint will emerge. What the stakeholder says is the actual problem may not be what you should actually focus on.