Author: Barry Morgenstern

Many cities have implemented behavior change programs in an attempt to get drivers to stop running red lights. Specifically, they put cameras at traffic lights and the driver gets mailed a ticket if they run a red light. These cameras are extremely effective at reducing the number of drivers who run red lights. Unfortunately, drivers do this by frequently stopping short and dramatically increasing the number of rear-end incidents.

Applied Behavior Analysis has a whole literature on how making one behavior change often impacts many other unplanned behavior changes. Sometimes, the unplanned behavior changes may be positive as in this example. However, I think that negative side effects happen in practice much more than is usually appreciated.

I have previously argued that we should both think ahead about possible negative side effects and make plans to prevent them. This is especially true with programs to improve staff behaviors. Planning is a good start, but we would also like a measurement. That’s pretty hard. How do you measure a negative side effect that you haven’t planned?

Well, of course, you have to spend time talking to staff. I strongly suspect how you ask about negative side effects matters a lot. If you ask staff, parents, or others, “How is everything going?” or “Are you doing all right?” The likely answer is “good” or “fine.” If you truly want to dig into the problems of negative side effects, it is necessary to be more direct. When asking, you need to assume that there are negatives still occurring, or else you substantially reduce the chances that you will be told about them. Use statements like:

“It looks like the program to reduce self-injury is going great, what problems have you been experiencing?”

“All programs appear to be going fantastic right now, what are your current 3 biggest problems?”

In other words, unless we are at a point where the child no longer requires intervention, there will still be big problems to address. Some of them may be negative side effects of programming; others may be challenges we have yet to address. Perhaps you don’t want to do this too much. We want to keep an overall positive environment and not having everyone looking for the negatives all the time. In my view, this is a subtle but important skill for BCBAs.

During the planning stages of working with children with autism, it is important to take time to think through the long-term implications of your program, look for potential negative side effects, and in general be very thoughtful before implementing something new.

But things change a bit when you are actually sitting with the child. Now, seconds matter. You don’t have time to hesitate and think through all your options. But new staff who generally know what to do, yet aren’t fluent with their skills, may hesitate out of fear that they might mess something up or be criticized for making an error.

When shaping a new skill, small errors are not likely to mess up a program, especially if you learn from them. If your prompt is off slightly, if you don’t reinforce at exactly the right time, or don’t say exactly the right thing, those mistakes can easily be corrected. But if people are afraid of even making small errors, training is sure to take MUCH longer than it should. Encourage people to “just do it.” Small errors can be fixed later.

Of course, supervisors to be clear on when staff should not “just do it,”–anything that would potentially create a safety issue, impact the dignity of the child, or hurt rapport in the relationship.

But as a general rule, when staff are in that awkward phase of having completed training and have demonstrated accuracy in implementing the skills, but are still not fluent or confident in their skills, “just do it” is usually great advice.

When I was a teenager, one of my go-to snacks was chopped chicken liver that my mom bought fresh from the Jewish deli. I would often sit with a large container of chopped chicken liver, crackers, and some pineapple juice and eat a ton of it. Several years later, I saw a can of chopped chicken liver while shopping. I thought, wow, I haven’t had this in years, so I bought a can to have as a treat. It was so horrible that I couldn’t eat any of it. Other chopped chicken liver fans have told me similar stories. It turns out that chopped chicken liver out of a can is not the same as chopped chicken liver freshly made. Later in life, I went almost completely vegetarian–although not because chopped chicken liver out of the can was so disgusting.

It is easy to get confused when things have the same name but are of dramatically different quality. Fresh chopped chicken liver is not the same as chicken liver out of a can. Some parents, teachers, and school district administrators have worked with BCBAs before and might have had a bad experience with low quality services. You have probably started new cases and heard things like this:

“We tried applied behavior analysis and it didn’t work.”

“We worked with Dr. X, BCBA-D and the behavior just got worse.”

“He wasn’t successful with the ‘my way’ program”

It could be that unusual circumstances prevented the child from being successful previously (e.g., medical issues). But it’s much more likely that this is a chopped-chicken-liver-out-of-a-can problem. In all likelihood the service that the person previously received was low quality. Although lots of people in the field are working on this problem, it is very hard to get good measurements to help people distinguish high-quality programs from low-quality programs.

The question now becomes how to show new clients that you are offering is different from what they have had before. There isn’t an easy answer to that question, but I think two things help tremendously. First, invite the person to watch sessions. Just seeing a couple of sessions can make a huge difference. Most people can see the difference between a high-quality and low-quality program relatively quickly. Second, make sure that the person notices the step-by-step progress that the child is making each session. When people see tangible evidence of a child’s success, they usually become a believer.

Some children with language delays have difficulties when they don’t understand when something is going to happen. For example, I once worked at a school where the buses lined up outside about 45 minutes before dismissal. I was working with four children who would see the bus pull up and start to get ready to leave. When we tried to explain that it wasn’t time yet, it led to severe problem behaviors.

The problem was very clear. Getting on the bus was motivating, and the children didn’t know when it was time. What we did was simple. We bought an alarm clock with a unique sound to ring when it was time to get on the bus. When the alarm would ring, we’d all rush around – OK, get your coats, get your backpacks, time to go! It was extremely successful. Within a week or two, all the children learned to wait for the alarm before packing up to go home, and it completely eliminated problem behaviors. Of course, as I think back, it might have been even better to make it so that the kids weren’t dying to get out of school. But that’s a topic for another day.

Over the years, I’ve replicated this type of procedure many times for a variety of similar problems. Now, we use apps or timers on our phones or iPad but the idea is still the same–send a clear message about when the preferred activity will and will not be available. Preschoolers who are concerned about when mom will pick up. Students who are concerned about when it will be time for lunch, recess, or gym.

I’ve even had success using this procedure with some children about events occurring a very long time in the future. For example, if the child doesn’t understand how long it will be until Christmas, getting a calendar and marking off each day until the highly preferred event occurs can be extremely successful. That can take some training with successive building up the number of days, but several parents have found it extremely successful.

This isn’t my idea. What I’ve done here is take a thoroughly researched procedure and extend and modify it a bit to solve practical problems.

Applied Behavior Analysis (ABA) has essentially won the argument over the need to have data to guide treatment decisions. Now, pretty much everyone accepts that data will guide clinical decision-making.

The problem is that BCBAs often use data that are not very useful for clinical decision-making. One example I have frequently talked about is problem behavior data that are collected across an entire school day. Often, these types of graphs will show wide variability in the data. But, in most cases, we don’t have any indication as to why since many of the variables are uncontrolled–Today was a substitute teacher; a peer called the student a mean name on the playground; the math assignment was more difficult than usual, etc. Often it is hard to tell what causes what.

The combination of these two factors causes a conflict that leads to bad decisions. Specifically, we have taught everyone to expect to see the data. We want them to look at the data. When there is a meeting, everyone wants to see the graph of how Johnny is doing with his problem behaviors. The pressure of showing the graphs at meetings leads to some bad decision-making. BCBAs tend to do things like teach staff to avoid all difficult situations to make the data look better. This is unlikely to lead to success in the long run.

Now, temporarily avoiding difficult situations that the client isn’t ready to handle is often a smart strategy. The problem is that some BCBAs use the reduction in problem behaviors as evidence of progress. If the client has problem behaviors during math, making the math easier or temporarily avoiding math all together may be appropriate in some circumstances. But we can’t claim that the resulting reduction in problem behavior represents “progress.”

What’s the solution? Simple. We need to teach people what types of data matter. In the example above, don’t show data on random uncontrolled incidents. Instead, show data in specific contexts where we are teaching the child to handle a difficult challenge. Now we can fairly evaluate as to whether an intervention is working on not working. We then work through each challenge until the child is successful in all contexts.

Of course, that is not as easy as it sounds. It takes time to explain this to administrators, teachers, parents, and others. But once people understand this and we are using the right data to make decisions real progress is much more likely.