Toward trauma-informed applications of behavior analysis

On the efficacy and efficiency of treating pediatric feeding disorder

Inappropriate mealtime behavior (IMB) is a type of feeding challenge within the broader class of food refusal. The purpose of this study was to critically analyze the efficacy of interventions for the treatment of IMB through a meta-analysis of research using single-case experimental designs. We examined the extent to which different interventions resulted in decreases in IMB while also producing increases in food acceptance. This meta-analysis was also used to examine the efficiency of different interventions in achieving clinical significance. We identified 38 studies involving 266 cases in which IMB was treated with a behavioral intervention. The results indicated interventions that combined escape extinction and non-escape extinction had greater effect sizes for both reducing IMB and increasing food acceptance than either escape extinction alone or non-escape extinction alone. However, interventions that included escape extinction were slightly less efficient at decreasing IMB than were interventions that did not include escape extinction. We discuss the implications of these findings and provide recommendations for future research.

Implementing culturally responsive and trauma-informed practices with checklists and goal setting

We discuss the use of two empirically validated behavior-change methods-checklists and goal setting-and designed a checklist to assist behavior analysts in improving their behavioral services to be more culturally responsive and trauma informed. We also present pilot data evaluating the use of the checklist and goal setting on the inclusion of culturally responsive and trauma-informed practices in behavior support plans designed for students in a public school. The training package was effective for both participants, and the participants' weekly goals corresponded to the observed changes in their behavior plans. Moreover, both participants strongly agreed that the checklist was valuable and easy to use and reported increases in their perceived abilities to implement culturally responsive and trauma-informed practices posttraining.

Affirming Neurodiversity within Applied Behavior Analysis

Criticisms of applied behavior analysis (ABA) from the autistic community continue to intensify and have an appreciable impact on research, practice, and conversation in stakeholder groups. ABA providers aspire to increase quality of life for autistic people; thus, it is imperative for providers to listen with humility and openness to the population we serve. Autistic individuals have unparalleled expertise in their own lives and their own communities. The concerns raised by the autistic community cannot, morally or ethically, be swept aside. There may be a misguided and harmful tendency to devalue concerns due to the speaker's identification as autistic or due to their difference in professional credentials. The concept of neurodiversity can help the ABA field respond to these concerns and collaborate with the largest stakeholders of our services, the autistic clients we serve. This article summarizes some of the key criticisms that autistic advocates raise concerning ABA, discusses the social model of disability and the neurodiversity paradigm, and proposes practical guidance to help the field of ABA integrate neurodiversity and thereby evolve our research and practice. By openly acknowledging the criticisms against ABA and recognizing how we can do better as a field, we believe we can take practical steps towards a profession and a society that more fully embraces inclusion.

Using the ADDIE Model of Instructional Design to Create Programming for Comprehensive ABA Treatment

ABA research abounds with articles on increasing or decreasing a small set of behaviors. These articles fit nicely within the framework of Focused ABA Treatment in which the goal of treatment centers on only a few behaviors. However, many behavioral practitioners spend most of their time developing Comprehensive ABA Treatment in which a large number of behaviors are systematically changed across multiple developmental domains. Few resources are available to help in designing and implementing such programming. This article presents a model from the field of instructional design for the development of comprehensive programming. Applying the ADDIE model-Analyze, Design, Develop, Implement, Evaluate-the article identifies a consistent process to follow, critical actions to take, and helpful resources to use when developing comprehensive programming for individuals with autism.

The Development and Acceptability of a Comprehensive Crisis Prevention Program for Implementation in Health Care Settings

INTRODUCTION

Behavioral crises are increasingly prevalent in health care settings. Existing programs, however, include procedures that lack adaptability, omit critical components, and deviate from clinical best-practice recommendations. Health care employees also continue to report lacking confidence for safely managing behavioral crises.

AIMS

We described the development and acceptability of a comprehensive crisis prevention program and its modification for a large pediatric health care system to help remediate the limitations of existing programs.

METHOD

Chi-square analyses evaluated the acceptability of the crisis prevention program pre- versus post-training and at 3- and 6-month follow-up times. For insignificant outcomes, logistical regressions identify whether responses differed between emergency-department and nonemergency-department employees.

RESULTS

Chi-square analyses were significant for 10 of 15 questions suggesting that employees were more confident in managing and communicating during behavioral crises post-training, and that this confidence was maintained. Logistic regressions found that emergency-department employees differed in some responses to the acceptability questionnaire than nonemergency-department employees over time.

CONCLUSION

The present crisis prevention program is adaptable to various settings and patients, and it is well received overall by employees. The safety of patients and employees is integral to the delivery of quality care and improving patient-provider relations.

Resolving Barriers to Continence for Children with Disabilities: Steps Toward Evidence-Based Practice

Behavior-analytic toilet training (BATT) methods to support urine continence have been reviewed and replicated in numerous studies. Despite empirical validations of BATT, children with disabilities may not experience successful toilet training nor access the associated health and social benefits of urinary continence. It is possible these outcomes are partially due to practical barriers that arise throughout urine training. In practice, barriers may interfere with toilet training to the extent that training is postponed or discontinued, resulting in long-term incontinence and other related problems. Examples of barriers include problem behavior, excessive urine retention, recurrent accidents, and excessive or insufficient independent self-initiations to toilet. Researchers have sometimes described strategies to address these types of barriers. However, practitioners may not be aware of these strategies because they are secondary to the purpose of an investigation and may only apply to a subset of participants. The purpose of this review article is to synthesize the collection of barrier solutions described in published research on urine training for children with developmental disabilities. Results may assist practitioners in modifying BATT according to an evidence-based practice framework until their clients overcome barriers to achieve urine continence.

Reflections and Critical Directions for Toilet Training in Applied Behavior Analysis

Achieving toileting independence is a critical skill that yields several benefits of pressing social, developmental, and health-related importance. The seminal behavioral approach to toilet training established the conceptualization of continence and framework for toileting research thereafter. Contemporary researchers continue to evaluate toilet training procedures that produce efficacious outcomes for young children that closely align with current applied behavior analysis (ABA) ethics and standards of practice. Despite the overall success of behavior-analytic toileting approaches, there are critical directions still worthy of consideration and investigation. In this paper, we acknowledge the seminal roots and many of the contemporary contributions. We also critically reflect on current practices while proposing necessary areas to advance behavior-analytic toilet training research.

Compassion in Autism Services: A Preliminary Framework for Applied Behavior Analysis

Many have suggested that a compassion-focused approach to applied behavior analysis (ABA) services may improve provider-client therapeutic relationships and has the potential to improve program acceptability and clinical outcomes experienced by our clients. In this article, radical compassion is defined and explored as a foundational approach to the implementation of ABA, with special emphasis on practical applications in the area of service delivery for families living with autism. In this framework for care, compassion is offered as a measurable repertoire and as a philosophical guidepost for future developments in the profession. This article explores preliminary tenets of compassion-focused ABA and their implications for practice. This approach is offered in the hope of moving the field toward a future of improved acceptability and sustainable consumer preference.

Autonomic Arousal and Adherence with Dental Appointments

Individuals with developmental disabilities sometimes display avoidance responses such as a lack of cooperation, aggression, and vocal refusal when completing health-care routines such as dental cleanings, physicals, and haircuts. This study evaluated the effects of both graduated exposure and a differential reinforcement procedure on the acquisition, maintenance, and generalization of cooperation with dental routines. In addition, autonomic responses were used as an ancillary measure of distress or comfort and were included in the decision tree of practitioner actions. Procedures were completed in a simulated context of a dental examination. The results of this study may lead to more comprehensive treatment plans that include the use of physiological responses in addition to cooperation with procedures as an indicator that an avoidance response has been extinguished. Assessing autonomic arousal may be a useful addition to the procedures of exposing participants to dental visit routines, to improve adaptation, cooperation, and generalization.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40617-023-00808-x.

The Science and Social Validity of Companion Animal Welfare: Functionally Defined Parameters in a Multidisciplinary Field

Social validity refers to the social significance and acceptability of intervention goals, procedures, and outcomes. Animal practitioners, who are often guided by the principles of ABA, lack the benefit of verbal participants (at least with respect to target animals) with which to assess a client's needs and preferences. The study of a learner's welfare is useful for determining areas where intervention is needed or how the learner feels about an intervention that is underway. Three tenets of animal welfare measurement include physiological function, naturalistic behavior, and affect, where affect refers to private events, including emotions, which are a function of the same variables and contingencies responsible for controlling public behavior. The development of new technologies allows us to look "under the skin" and account for subjective experiences that can now be observed objectively. We introduce the reader to tools available from the animal welfare sciences for the objective measurement of social validity from the learner's perspective.

Trauma-Informed Care for Individuals with Intellectual and Developmental Disabilities: From Disparity to Policies for Effective Action

People with intellectual disabilities (ID) are an often overlooked minority population. They experience significant health disparities and a high risk of exposure to traumatic events that can lead to stress-related disorders. Access to effective treatments for stress-related disorders is limited for people with ID due to a lack of appropriate assessments and common communication deficits. We discuss and analyze four factors that have led to these disparities: (1) historical segregation; (2) society's response to identification of trauma in vulnerable populations; (3) lack of accessible assessments and treatments for stress disorders in people with ID; and (4) communication deficits common in people with ID. Based on this analysis, we suggest behavior analysts advocate for policy development that would (1) increase acknowledgement of trauma in people with ID and mandate sharing of information about trauma across providers; (2) require observable and measurable goals be included in the assessment and treatment of trauma-related behavior change; and (3) increase funding for services and research in this area.

A practitioner's guide to emphasizing choice-making opportunities in behavioral services provided to individuals with intellectual and developmental disabilities

Promoting choice is a defining value guiding Positive Behavior Support (PBS) models for serving individuals with intellectual and/or developmental disabilities (IDD). The ability to make independent choices is of paramount importance to self-advocacy and self-determination. Promoting choice is also an essential commitment of trauma-informed care (TIC) in the provision of services to vulnerable individuals, as trauma often involves experiences in which an individual has no control over aversive events that occur, and choice-making opportunities can empower traumatized individuals to regain control over the environments they routinely encounter. However, incorporating meaningful choice making into behavioral programming is often more difficult than it seems. We synthesize the relevant, contemporary literature to provide professionals with actionable suggestions for incorporating choice making into everyday behavioral services. After summarizing the importance of promoting choice into behavioral services based on the values that define both PBS and TIC frameworks, we (a) offer a behavior-analytic interpretation of the skill of making choices, (b) synthesize key literature on how to teach choice making skills, (c) provide recommendations for the situations within one's care in which choice-making opportunities may be most beneficial, and (d) discuss some of the barriers and potential solutions to incorporating choice-making opportunities for individuals with IDD.

Assent in applied behaviour analysis and positive behaviour support: ethical considerations and practical recommendations

The term positive behaviour support (PBS) is used to describe the integration of the contemporary ideology of disability service provision with the clinical framework of applied behaviour analysis (ABA). Assent, the participation consent of those not legally able to consent, has gained recent popularity in the fields of ABA and PBS. The goal of assent-based ABA and PBS is a person-centered approach to assessment, intervention, and all other decision-making. In this model, the learner's assent withdrawal for participation is honored, whether it be a vocal 'no' or a non-vocal expression of verbal behaviour. There is currently a limited subset of studies that mention or utilize assent with learners in ABA or PBS. The lack of published research can make assent-based practices seem to be a choice of the practitioner. The authors of this manuscript seek to further define assent, illuminate the necessity of assent-based practices, and offer assent-based procedures in ABA- and PBS-based intervention.

Varying reinforcer dimensions during differential reinforcement without extinction: A translational model

Procedural arrangements of differential reinforcement of alternative behavior without extinction often involve presenting the same reinforcers for problem behavior and appropriate behavior, which is typically ineffective at reducing problem behavior and increasing an alternative response. However, manipulating reinforcement dimensions such that the contingencies favor the alternative response may improve treatment outcomes when using differential reinforcement of alternative behavior without extinction by increasing appropriate behavior and reducing problem behavior. We conducted this translational study with 32 college students completing a button-pressing task on a computer program in which they could engage in analogs to problem behavior and appropriate behavior. The effects of manipulating magnitude, immediacy, quality, and a combination of all three dimensions for the alternative response were evaluated. Overall, all dimension manipulations reduced the analog to problem behavior, with the largest reductions observed during the quality probe and the probe with all dimensions combined. These results support the notion that differential reinforcement of alternative behavior without extinction can be an effective form of treatment.

Effects of and preference for student- and teacher-implemented good behavior game in early elementary classes

Disruptive behavior during instruction is a common problem in elementary classrooms. One intervention to reduce disruptive behavior is the Good Behavior Game (GBG). In this study, the students of 2 early elementary classrooms experienced 3 versions of the GBG: experimenter-implemented, teacher-implemented, and student-implemented. The effects of the GBG on disruptive behavior and peer interactions were evaluated using a combined reversal and multielement design. Student preference for conditions was assessed via a group arrangement of a concurrent-chains preference assessment. All versions of the game reduced disruptive behavior compared to baseline, but the rate of disruptive behavior was slightly higher during the teacher-implemented sessions in Class 1. Few peer interactions occurred during the game; however, negative interactions increased slightly in both classes during the GBG. Students overwhelmingly preferred the student-implemented version of the game. This study provides support for student implementation of the GBG and offers an approach to student shared governance in the classroom.

Bridging the gap between laboratory and applied research on response-independent schedules

In 1948, Skinner described the behavior of pigeons under response-independent schedules as "superstitious," and proposed that the responses were reinforced by contiguous, adventitious food deliveries. Subsequently, response-independent schedules have been of interest to both basic and applied researchers, first to understand the mechanisms involved, and later, as "noncontingent reinforcement" (NCR) to reduce undesirable behavior. However, the potential superstitious effects produced by these schedules have been challenged, with some researchers arguing that antecedent variables play a significant role. This paper examines the evidence for adventitious reinforcement from both laboratory and applied research, the results of which suggest that antecedent, nonoperant functions may be important in fully understanding the effects of NCR. We propose an applied-basic research synthesis, in which attention to potential nonoperant functions could provide a more complete understanding of response-independent schedules. We conclude with a summary of the applied implications of the nonoperant functions of NCR schedules.

Examining the perceptions of needs, services and abilities of Czech and North Macedonian caregivers of children with autism and trainers

Effective practices for supporting families with autistic children ensure a match between their needs and the expectations and competencies of the clinician. Applied behavior analysis (ABA) services are a common provision for serving autistic individuals. However, in regions where ABA is in its infancy, like the Czech Republic and North Macedonia, culturally relevant resources, regulations for practice, and standardized coursework are missing. In their absence, it is necessary to investigate the degree to which practitioners in the regions are meeting the behavioral needs of families. Assessing this match can set the stage for establishing more stable and effective services in the areas, as well as neighboring countries with similar historical foundations. Therefore, a survey was conducted to examine the perceptions of caregivers and trainers (those who self-identified as providing support to families with autistic children). A total of 233 caregivers and 204 trainers participated. Analysis of the survey responses verified the lack of behavioral knowledge on the part of the trainers, the apparent lack of access to ABA services for families in both regions, a potential misalignment between family needs and training targets, and the disparities between the two countries. The information evaluated here can be used to guide preservice training, dissemination efforts, and regulations surrounding behavioral practices.

Safety Learning in Anxiety, Pavlovian Conditioned Inhibition and COVID Concerns

Experimental studies of fear conditioning have identified the effectiveness of safety signals in inhibiting fear and maintaining fear-motivated behaviors. In fear conditioning procedures, the presence of safety signals means that the otherwise expected feared outcome will not now occur. Differences in the inhibitory learning processes needed to learn safety are being identified in various psychological and psychiatric conditions. However, despite early theoretical interest, the role of conditioned inhibitors as safety signals in anxiety has been under-investigated to date, in part because of the stringent test procedures required to confirm the demonstration of conditioned inhibition as such. Nonetheless, the theoretical implications of an inhibitory learning perspective continue to influence clinical practice. Moreover, our understanding of safety signals is of additional importance in the context of the increased health anxiety and safety behaviors generated by the COVID-19 pandemic.

Cultural responsiveness in applied behavior analysis: Research and practice

The new Ethics Code for Behavior Analysts requires that certificants engage in training related to culturally responsive service delivery (BACB, 2020). There is limited work in the area of culturally responsive evidence-based practice within our field. Therefore, it is incumbent on researchers and practitioners to identify best practices for working with diverse populations. Hence, the purpose of this paper is three-fold: a) to review research within and outside the field of ABA related to culturally responsive assessment and treatment and provide practice recommendations, b) to examine the extent to which current practices in behavior assessment and treatment align with aspects of culturally responsive practices, and c) to inspire research in the areas of behavior assessment and treatment to identify best practices with regard to culturally responsive behavior analytic practices. The content of this paper is grounded in the framework described by Beaulieu and Jimenez-Gomez (2022).

Cultural responsiveness in applied behavior analysis: Self-assessment

Culture has a substantial impact on a wide range of behaviors related to behavioral research and services such as rapport building, preferences for specific targets and treatments, communication, and even the quality of health care. The need for professionals in the field of applied behavior analysis (ABA) to incorporate culturally responsive practices is underscored by the current and projected increase in diversity in the United States. Further, the update to the Ethics Code (BACB, 2020) supports addressing diversity in behavior analytic practice. Self-assessment of one's values, biases, and culture are a critical step in delivering culturally responsive services. The purpose of this paper is three-fold: a) to introduce a framework for cultural responsiveness in ABA, b) to showcase research and practice recommendations from within and outside the field of ABA in the area of self-assessment, and c) to inspire research in self-assessment to support cultural responsiveness in ABA.