POOGI for ABA

Inclusion programming can be wonderful. Many children with autism and other developmental disabilities can learn well in inclusive settings. The children in the class without autism or developmental disabilities often benefit too. Sometimes meaningful friendships can develop and flourish.

The problem comes when the child is in desperate need of other therapy that cannot be delivered in the inclusive classroom. This might be certain types of communication training, social skills programming, learning to develop self-control over serious problem behaviors or self-help skills. Often, teams decide that the need to participate as much as possible in the inclusion setting is the priority despite obvious other needs. Now, unless the skills learned in the inclusive setting are meeting natural contingencies, they likely won’t maintain, and in the long run won’t matter towards having a higher quality of life.

I think this is another situation where it is easy to get fooled by the data.  Likely, something like this happened. The team is sitting at a meeting and the teacher, speech pathologist, occupational therapist, or other team member tells a story like this:

Let me tell you what happened yesterday! At recess, he was initiated playing with another peer. They were engaged, talking, laughing, and happy! It lasted at least 5-minutes. I was so happy that I started to cry.

It isn’t easy for the untrained eye to distinguish between situations where the child has made great progress in social skills that are likely to maintain and gains that will be fleeting. I’ve seen so many situations where it might look great in preschool or kindergarten, but by 4^th grade the child is circling the playground by themselves, and then by middle school they are in a segregated setting due to serious problem behavior.

If our goal is to make a real difference in the life of the children we work with, then it is essential that we speak up. Sure, sometimes many people might not like it. We’ve been here before and we know how this movie ends.

True friendships are not likely to develop and maintain if the child doesn’t have the skills needed. Sometimes these skills can be developed in inclusive settings. But other times there is critical therapy that needs to happen outside of that setting. It isn’t an easy thing to say to a crying kindergarten teacher or parent, but it is essential.

Behavior Skills Training (BST) is generally considered to be an essential part of training anyone who might need to be trained—parents, teachers, registered behavior technicians, or students who want to become BCBAs (Board Certified Behavior Analyst).

BST includes several things that are very helpful for training including:

1. Describe the skill and provide a rationale
2. Provide a written description of the skill
3. Model the skill for the learner
4. Ask the person to practice the skill
5. Provide feedback to the person on their performance of the skill
6. Continue until the person demonstrates the skill at a mastery level

The research on the effectiveness of BST is extensive. It is a very effective training procedure for a wide variety of skills. Frequently you will hear BCBAs say that I told them what to do and they still aren’t doing it! Well, why would you think they would be able to do it just because you told them what to do? Research has shown over and over that just telling them doesn’t work. You need to also provide training. Many skills need to be taught to BCBA students through BST. The odds of someone becoming a great BCBA without BST training are low.

One common obstacle when working in real world settings is that it is very difficult to use the student’s time to maximum effectiveness. The student may need training on a particular type of problem (e.g., functional assessment, natural environment teaching, chaining), but usually schedules don’t allow for us to move a student to a different client to maximize their learning. The client’s needs have to come first. I believe most people, while they get through all their supervision hours, could have used a lot more BST in different aspects of their training that simply didn’t work logistically.

That might be OK, as the BCBA should be considered a minimum qualification. Of course, our ethical guidelines teach us that we must seek supervision when we don’t have the relevant training and experience to handle a particular client problem. We all need a lifetime of Poogi.

What I fear is that BST might teach an unintended lesson. Specifically, someone else is responsible for my learning. In my view, in order to be a professional, you need to be active in trying to POOGI. That means independently finding relevant peer-reviewed research, studying that research, asking lots of questions, initiating to take on new projects, taking data on your own performance, following up with study of what you learned at conferences, connecting with other professionals who specialize in areas where you are weak, and probably hundreds of other activities. Certainly, supervision can encourage these behaviors, and I believe they often do. But are we as careful in fading our prompts in supervisees as we are with clients? I doubt it. BST is an essential training activity for supervisees. But if you aren’t careful, it will create prompt dependence.

We can see whether a behavior changed on the graph, but not whether a program was effective. In behavior analysis effectiveness does not just mean that the behavior changed. It means the change made a socially significant difference in the person’s life. When you look at the graph and you see the child learned ten words, that’s great. But did you make a significant difference in the child’s life? If not, the program was not effective.

After graduate school, one of the first cases that I took on involved an adolescent with extremely dangerous aggressive behaviors. At baseline, there were hundreds of aggressive behaviors per day. Often staff were hurt. It was a dangerous place to work. He always had a staffing ratio of 2:1. Through intensive effort, we dramatically reduced this behavior and increased participation in a wide variety of activities. In fact, most days he had zero episodes of problem behavior. I graphed this data on a per month basis and it looked amazing! After a year, when I left that job, he had only 3 or 4 episodes per month.

The graphs appeared to tell a great story. The behavior was reduced more than 99% and participation in a variety of activities was up substantially. But really, this program wasn’t very effective. That’s because the 3 or 4 episodes that happened each month often involved someone going to the hospital or emergency room.  It had no substantial impact on his quality of life. He still had a restrictive staffing ratio. He sill had limited opportunities to participate in the community.

Now, it’s not that what we did was worthless. Obviously, the program had a big impact. It’s just that what we did was just the beginning of what was needed. Just changing the behavior isn’t sufficient. We must change the behavior enough that it has a real substantial impact on the person’s life or in the long run it won’t be worth much.