Ethical Considerations for Interdisciplinary Collaboration with Prescribing Professionals

Behavior Analysts' Use of Treatments for Individuals with Autism: Trends within the Field

Previous surveys revealed the majority of certified behavior analysts reported using applied behavior analysis (ABA) as a treatment for individuals on the autism spectrum. However, some certificants have also reported using treatments without evidence (Schreck et al. Behavioral Interventions, 31(4), 355-376, 2016; Schreck & Mazur Behavioral Interventions: Theory & Practice in Residential & Community- Based Clinical Programs, 23(3), 201-212, 2008). The field of ABA has undergone many changes in the last five years. This survey evaluated trends in the use and variables influencing the use of autism treatments over that time. Results indicated that study participants (N = 921 BCBA-Ds, BCBAs, BCaBAs, and RBTs) were significantly less likely to report current use of ABA and some unestablished treatments (e.g., DIR Floortime, sensory integration therapy) than participants in 2016 (Schreck et al. Behavioral Interventions, 31(4), 355-376, 2016). Participants frequently cited persuasion by others as an influence for their treatment selections. Because behavior analysts' use of unestablished treatments may be detrimental to client outcomes and the reputation and success of the field of ABA, future research is needed to identify methods for increasing behavior analysts' use of empirically supported treatments.

The Ethical Obligations, Barriers, and Solutions for Interprofessional Collaboration in the Treatment of Autistic Individuals

With an estimated 1 in 44 children having been diagnosed with autism and given the variety of types of service providers that treat autism, collaboration among these professionals is a necessary part of the overall treatment package for an autistic individual. However, like with any professional skill, competence in collaborating effectively must be developed, especially because behavior analysts have been criticized for being resistant to collaboration. Competence with collaboration may be developed through coursework, professional development opportunities, and supervision by someone who has demonstrated competence with collaboration. With the 2020 update to the Ethics Code for Behavior Analysts, the behavior analyst's role in collaborating with other professionals has been clarified by several expectations. Current literature also provides additional guidance on the potential barriers to collaboration as well as recommendations for how to support a collaborative team. In order to facilitate successful collaboration, it is also important to evaluate the effectiveness of the collaborative team and to take advantage of opportunities to learn about the methodologies and perspectives of the other professionals to ensure that the client's best interests are met.

Examination of Ethical Decision-Making Models Across Disciplines: Common Elements and Application to the Field of Behavior Analysis

Human service practitioners from varying fields make ethical decisions daily. At some point during their careers, many behavior analysts may face ethical decisions outside the range of their previous education, training, and professional experiences. To help practitioners make better decisions, researchers have published ethical decision-making models; however, it is unknown the extent to which published models recommend similar behaviors. Thus, we systematically reviewed and analyzed ethical decision-making models from published peer-reviewed articles in behavior analysis and related allied health professions. We identified 55 ethical decision-making models across 60 peer-reviewed articles, seven primary professions (e.g., medicine, psychology), and 22 subfields (e.g., dentistry, family medicine). Through consensus-based analysis, we identified nine behaviors commonly recommended across the set of reviewed ethical decision-making models with almost all (n = 52) models arranging the recommended behaviors sequentially and less than half (n = 23) including a problem-solving approach. All nine ethical decision-making steps clustered around the ethical decision-making steps in the Ethics Code for Behavior Analysts published by the Behavior Analyst Certification Board (2020) suggesting broad professional consensus for the behaviors likely involved in ethical decision making.

Teaching clinicians and nurses to prepare for and present at interdisciplinary meetings through behavioral skills training

Behavior analysts frequently collaborate with interdisciplinary colleagues to share information and make decisions about client services. This study evaluated the effects of behavioral skills training on preparation for and presentation during interdisciplinary review team meetings by clinicians (n = 4) and nurses (n = 4) at a residential school for students with intellectual and neurodevelopmental disabilities. The primary dependent measure was the percentage of preparation and presentation steps from task-analyzed behavior checklists that the participants implemented correctly. As evaluated by multiple-baseline designs, the participants improved their preparation and presentation skills to nearly 100% following behavioral skills training, maintained performance 1 month after the study, and rated training positively. We discuss elements of the training program, practice implications, and research directions.

Teaching Graduate Students to Translate Nonbehavioral Treatments Into Behavioral Principles

Behavior analytic translations of nonbehavioral treatments were recommended by Brodhead in Behavior Analysis in Practice, 8(1), 70-78 (2015) as part of a decision-making framework for practitioners working on interprofessional treatment teams. Professionals from different disciplines often have overlapping scopes of practice and competence, yet each recommends interventions according to their discipline-specific worldview and training. Nonbehavioral treatment recommendations may be especially challenging for behavior analytic practitioners who are committed to the science of human behavior and who are also ethically obligated to work cooperatively and in the best interest of the client. Learning to translate nonbehavioral treatments into behavior analytic principles and procedures may function as a valuable means of improving professional judgment, thereby promoting evidence-based practice and effective collaboration. Behavioral translations may expose procedures that are, in fact, conceptually systematic, creating more opportunities for behavior analysts to partner in interprofessional care. Using a behavioral skills training package, graduate students of applied behavior analysis were taught to translate nonbehavioral treatments into behavior analytic principles and procedures. All students produced more comprehensive translations following training.

Psychotropic Medication Monitoring in a Human Services Organization for Children with Autism Spectrum Disorder: Description and Evaluation of Interdisciplinary Team Review

Children with autism spectrum disorder (ASD) are often prescribed psychotropic medications but pharmacotherapy is typically conducted and evaluated based on clinical judgement without reference to objective measurement of treatment effectiveness and combined efficacy of pharmacological-behavioral interventions. We describe an interdisciplinary review team (IRT) model at a human services organization for children with ASD that was designed to standardize a process of psychotropic medication monitoring through (1) coordinated involvement of medical, nursing, behavior analyst, and special education professionals, (2) parent-guardian participation, (3) data-driven decision making, and (4) high-level administrative support. Our description includes case illustrations of medication reduction-elimination trials with five students and social validity assessment of IRT clinicians, nurses, and parent-guardians. Key components of the IRT model are emphasized with associated practice and research recommendations.

Incorporating merged treatment procedures for children with autism: A case report

We examined interprofessional collaboration in a pre-service training model which incorporated the merging of three treatments: Occupational Therapy, Speech-Language Pathology, and Applied Behavior Analysis. We examined the effects of changes in the clinician interprofessional skill repertoire on therapeutic outcomes for children with Autism Spectrum Disorder. Three licensed professionals modeled core techniques from their respective professions to establish benchmark standards for skill demonstration in the treatment of children with autism. Treatment phases were implemented sequentially targeting multiple therapist and child behaviors within a multiple-baseline across participants' single case experimental design. Therapist skills improved to show a diverse repertoire of intervention techniques to match supervisor proficiencies. These interprofessional skills were delivered simultaneously in a timely and efficient manner. Assessed outcomes for children with autism included increased frequency of verbalizations, engagement during adult-directed interactions, visual-motor task productivity, and improved postural alignment. The study suggests that integrated training across interprofessional techniques enhanced a diverse repertoire of clinician skills, while systematically demonstrating child improvement on many interprofessional treatment goals.

Continuum of Care Screener: A Risk Mitigation Tool to Guide Decision Making When Environmental Factors Affect Service Delivery

Navigating novel, unpredicted service disruptions can be complex and unparalleled. To effectively handle service interruptions, board certified behavior analysts (BCBAs®) must make sound clinical decisions, comply with the Behavior Analyst Certification Board’s Ethics Code for Behavior Analysts (2020a), and critically engage in ongoing risk/benefit assessments for each individual client. Unfortunately, most BCBAs do not receive coursework, training, or fieldwork supervision in advanced risk mitigation. Those who have been practicing longer may have more experience in organizational systems and mitigating risk; however, half of all BCBAs have been certified in the last 5 years and two thirds have been certified in the last 7 years (BACB, 2021). This rapid growth of the profession poses significant challenges in navigating novel situations outside of the practitioner’s scope of competency and learning history. In this article, we present a systematic formalized approach to risk management through an organizational behavior management lens. The article includes a screening tool, a summary of the model, and case examples of ongoing risk assessment during unexpected service disruptions. This screener is designed to help BCBAs think critically and systematically as they consider social and contextual factors across stakeholders, the client’s behavioral status and treatment needs, state policy and law, and professional and ethical obligations during the decision-making process.

Interdisciplinary Collaboration Training: An Example of a Preservice Training Series

In recent years, there has been discussion of the need for training behavior analysts in collaboration skills. There is some consensus that these skills are needed to improve outcomes with clients and with colleagues. Specifically, students of behavior analysis and behavior-analytic practitioners need to learn the skills associated with functioning effectively in interdisciplinary teams. At Melmark, a model of training in this skill set has been developed and integrated into supervision modules for those seeking Board Certified Behavior Analyst certification. In this model, supervisees are exposed to information about the expertise and value of the allied professions of speech-language pathology, occupational therapy, physical therapy, and developmental pediatrics. Rotations are done within these fields to expose trainees to the expertise of these fields and to build skills in collaboration with members of those professions. Trainees are also assigned tasks that require them to identify the contributions of other professions and display appropriate collaborative behavior. Future directions for the model are discussed, including extending it across the organization and developing performance-based assessments and social validity measures.

Standards for Interprofessional Collaboration in the Treatment of Individuals With Autism

Interprofessional collaboration has become an essential component in the treatment of individuals with autism spectrum disorder, as practitioners from a range of disciplines are often necessary to address the core features and co-occurring conditions. Theoretically, such cross-disciplinary collaboration results in superior client care and maximal outcomes by capitalizing on the unique expertise of each collaborating team member. However, conflict in collaborative practice is not uncommon given that the treatment providers come from varying educational backgrounds and may have opposing core values, fundamental goals, and overall approaches. Although the overarching interest of each of these professionals is to improve client outcomes and quality of life, they may be unequipped to effectively navigate the barriers to collaboration. This article reviews the potential benefits and misconceptions surrounding interprofessional collaboration and highlights common sources of conflict. As a proposed solution to many of the identified issues, we offer a set of standards for effective collaborative practice in the interprofessional treatment of autism spectrum disorder. These standards prioritize client care and value each discipline's education and unique contributions. They are intended to function as core standards for all treatment team members, promote unity, prevent conflict, and ultimately help practitioners achieve the most integrated collaborative practice among professionals of varying disciplines.

Ethical Considerations of Behavioral Feeding Interventions

Children with autism spectrum disorder (ASD) often display repetitive and restrictive patterns of behavior, which can be seen in food selectivity and other feeding problems. Feeding problems in children with ASD not only lead to medical complications for the child but also can lead to increased caregiver stress. In order for behavior analysts to ensure adherence to the Professional and Ethical Compliance Code for Behavior Analysts, many factors need to be addressed prior to and during feeding assessments and interventions. The need for interdisciplinary collaboration and ethical situations that may arise are reviewed. The purpose of this article is to assist the behavior analyst in determining best practices for feeding assessments and interventions while maintaining ethical compliance.

Collaboration between Behavior Analysts and Occupational Therapists in Autism Service Provision: Bridging the Gap

Interdisciplinary collaboration is challenging, but necessary, to meet the needs of individuals with autism spectrum disorder. Among the dyadic interactions in interdisciplinary teams, the relationships between occupational therapy practitioners and board certified behavior analysts are uniquely challenging. The disciplines define evidence-based practice differently and approach intervention from different angles. Furthermore, there are fundamental differences in worldview between the disciplines. Both disciplines offer necessary treatment, and successful collaboration between these disciplines is essential for maximizing outcomes. Hence, finding ways to help bridge the gap between these professions, in particular, is essential. Common barriers to developing collaborative alliances include misperceptions of the other discipline, differences in terminology, and unprofessional behavior. This article reviews the history and foundational concepts of both disciplines, and the common approaches associated with each. In addition, models of collaboration are discussed, with suggestions for enhancing interdisciplinary communication and treatment. Successful collaborative treatment is predicated on an understanding of the value and expertise offered by different disciplines, and requires mutual respect and professional dialogue.

Six Useful Websites for Practitioners Working in Schools

A substantial, and seemingly increasing, number of Board Certified Behavior Analysts work in pre-K-12 schools. Many of them will be unfamiliar with the roles and activities of other school professionals, as well as with the structure, function, and mandates of schools. This article introduces 6 websites that are devoted to education. Accessing these free and user-friendly sites can provide practitioners with information and training activities that will help them function comfortably and competently in schools and benefit their clients to a greater extent. Our purpose in writing this article is to introduce and recommend these websites.

Ethical Considerations in Clinical Supervision: Components of Effective Clinical Supervision Across an Interprofessional Team

Within the practices of behavior analysis, education, occupational therapy, physiotherapy, speech-language pathology, and other health professions, professional practice focuses on each discipline's ethics, assessment, and treatment practices. However, maximizing outcomes for some clients is achieved only by combining the strengths of multiple disciplines to include all the competencies required for comprehensive client care. Thus, understanding and acquiring the core competencies for working collaboratively within an interprofessional framework is essential for working together effectively to garner the best outcomes for clients. Furthermore, the interprofessional team clinical supervisor has the added responsibility of ensuring optimal client outcomes while managing a diverse group of professionals, each with their own set of perspectives, clinical training, and evidence-based practices. In many areas of applied practice, the behavior analyst assumes the role of interprofessional clinical supervisor, which necessitates additional training in collaboration, supervision of allied professionals, and ethics. Successful interprofessional and collaborative working relationships require a number of key competencies and subcompetencies as outlined by the Interprofessional Education Collaborative, as well as knowledge of others' ethical and professional codes and/or guidelines for professional conduct, along with additional training and resources in the navigation and handling of ethical dilemmas among disparate team members. Working together and maintaining professional relationships within an interdisciplinary team are fraught with barriers and issues that may impede collaboration. The interprofessional team clinical supervisor requires various strategies, processes, and resources to enable them to navigate challenges and assist the team in working cohesively to achieve more positive client outcomes.

Toward the Development of a Functional Analysis Risk Assessment Decision Tool

Risk-benefit analyses are essential in the decision-making process when selecting the most effective and least restrictive assessment and treatment options for our clients. Clinical expertise, informed by the client's preferences and the research literature, is needed in order to weigh the potential detrimental effects of a procedure against its expected benefits. Unfortunately, safety recommendations pertaining to functional analyses (FAs) are scattered or not consistently reported in the literature, which could lead some practitioners to misjudge the risks of FA. We surveyed behavior analysts to determine their perceived need for a risk assessment tool to evaluate risks prior to conducting an FA. In a sample of 664 Board Certified Behavior Analysts (BCBAs) and doctoral-level Board Certified Behavior Analysts (BCBA-Ds), 96.2% reported that a tool that evaluated the risks of proceeding with an FA would be useful for the professional practice of applied behavior analysis. We then developed an interactive tool to assess risk, which provides suggestions to mitigate the risks of an FA and validity recommendations. Subsequently, an expert panel of 10 BCBA-Ds reviewed the tool. Experts suggested that it was best suited as an instructional resource for those learning about the FA process and as a supporting resource for early practitioners' clinical decision making.

Culture Always Matters: Some Thoughts on Rosenberg and Schwartz

The purpose of this paper is to draw attention to and highlight some particularly enlightening arguments described by Rosenberg and Schwartz (2019). First, I emphasize the importance of the role of culture in ethical analysis and describe how the Behavior Analyst Certification Board (BACB) Professional and Ethical Compliance Code for Behavior Analysts (2014; hereafter referred to as the BACB Code) unintentionally underplays the importance of culture. Second, I express support for the model of ethical analysis proposed by Rosenberg and Schwartz and explain how their model provides an excellent and much-needed framework for the observation (and subsequent study) of ethical decision-making in behavior-analytic practice. Finally, I go all in and join Rosenberg and Schwartz in their call for scholars to critically analyze and discuss the BACB Code and to challenge the status quo (or call into question those who do). Such a discussion is healthy for our science and understanding of ethics and behavior analysis.

Multidisciplinary Teaming: Enhancing Collaboration through Increased Understanding

In an effort to provide clarity about the unique contributions of several professions within the context of multidisciplinary treatment, we reviewed the definitions, philosophical underpinnings, and national requirements pertaining to both scopes of practice (i.e., model licensing acts, legislation, and regulatory boards) and training (i.e., task lists, accreditation standards and course requirements, and exam blueprints) of 4 behavioral health professions. The professions we selected (behavior analysis, psychology, speech-language pathology, and occupational therapy) are likely to provide treatment alongside one another and often to the same clients. In a review of documents pertaining to scopes of practice and training for each profession, we found overlapping content. However, the similarities between professions diminished when we reviewed more specific guidelines such as learning objectives, educational requirements (i.e., coursework), supervised clinical experience (e.g., internships), and national examinations. This was especially true when considering each profession's underlying approach to treatment (i.e., philosophical underpinnings) and, hence, service activities. We discuss our findings in light of service overlap and make a call for greater collaboration between professions, as related to the separate content knowledge and expertise of professionals in each field and the impact on client outcomes.

Addressing Medical Issues in Behavior Analytic Treatment

This article offers strategies to help behavior analysts address medical issues which may affect behavioral intervention, beginning with the intake process and continuing through treatment and the coordination of care with other healthcare providers. The Behavior Analyst Certification Board's ethical guidelines for seeking medical consultation are reviewed. The importance of documenting clients' medical histories at intake and keeping updated medical files is emphasized. Behavioral manifestations and data patterns that may serve as red flags for medical problems are reviewed, with an emphasis on clients with limited verbal skills who cannot describe their symptoms. Multiple aspects of the behavior analyst's role in the coordination of care for clients' medical conditions are discussed.

A Call for Discussion About Scope of Competence in Behavior Analysis

The field of behavior analysis has defined its scope of practice through credentialing and licensure efforts. However, scope of competence in behavior analysis has received little discussion. Scope of competence refers to activities that the individual practitioner can perform at a certain criterion level (e.g., the functional analysis is conducted accurately and safely, a skill acquisition program includes critical program components and establishes accurate stimulus control). Given the successful efforts of behavior analysts in growth and recognition of the field, it is time for a robust conversation about scope of competence for the field of behavior analysis. This discussion can clarify how behavior analysts self-evaluate their own scope of competence and how they might expand their scope of competence if the needs of consumers require practitioners to expand into new areas.

Board Certified Behavior Analysts and Psychotropic Medications: Slipshod Training, Inconsistent Involvement, and Reason for Hope

People with autism spectrum disorder often receive psychotropic medications and two drugs, risperidone and aripiprazole, are approved for treating "irritability" in this population. A number of authors have suggested that behavior analysts can contribute to the prudent use of such drugs, but little is known regarding Board Certified Behavior Analysts' involvement in practices relevant to the use of psychotropic drugs. We e-mailed Board Certified Behavior Analysts an anonymous web-based survey regarding such practices. A majority of respondents work with individuals with autism spectrum disorder who take at least one psychotropic medication but respondents' training relevant to psychotropic medications is inconsistent. Many report that their training is inadequate, they do not regularly work as part of interdisciplinary teams concerned with medication, and behavior-analytic interventions are not typically evaluated before drugs are prescribed. Nonetheless, the majority of respondents reported that medications sometimes produce beneficial effects. Those involved in training behavior analysts should consider the competencies needed for graduates to work effectively as members of teams concerned with the optimal use of medications and how to foster and assess those competencies. Behavior analysts should also work to develop and implement strategies that foster collaboration with psychiatrists and other physicians. • Psychotropic drugs are often prescribed for people with autism, and both risperidone and aripiprazole are approved for reducing "irritability," which comprises self-injury, aggression, tantrums, and other challenging responses. • Respondents are not consistently involved in monitoring the effects of psychotropic drugs, which are often administered prior to evaluating an alternative, less restrictive, intervention. • Respondents are not trained consistently with respect to matters relevant to psychotropic drugs, and many apparently are not trained adequately. • People involved in training behavior analysts should consider the competencies needed for graduates to work effectively as members of teams concerned with the optimal use of medications and how to foster and assess those competencies. • Behavior analysts should also work to develop and implement strategies that foster collaboration with psychiatrists and other physicians.

How to Identify Ethical Practices in Organizations Prior to Employment

Behavior analysts likely can evaluate multiple organizations prior to accepting a job due to recent increases in the number of organizations providing ABA services. We argue that evaluating the ethical values of an organization is paramount during the job search process. We provide strategies for evaluating the ethical values of an organization prior to employment and describe considerations from the pre-application process through contract negotiations. Ultimately, we add to the growing body of literature that provides guidance for common problems behavior analysts may face over the course of their careers.