It’s taken me a few days, but I want to continue the discussion on the changes coming to my practice. I may be long at times when I want to be short, but I quite easily give long explanations lol. I will also be putting these on both the Kreed blog and No Limits Blog.
How many parents have sent their child to therapy at 4? Here is the programming and the behavior plan. Now that child is 10. Here is that programming and behavior plan. But wait, six years later, the same behaviors are on that behavior plan, but may just look a little different. It’s been six years. You ask why, why is my child still acting this way? A typical ABA behavior plan includes what is called a Functional Behavioral Assessment (FBA). An FBA can consist of a number of items, typically left up to the behavior analysts discretion. They often have indirect assessments (closed-ended questionnaires with family and staff) and descriptive assessments (antecedent (what happens before a behavior), behavior, consequence (what happens after a behavior) data while directly observing a client as well as other descriptive observations when directly with the child). Based on those two assessments, often behavior analysts think they have an understanding of the topography (what a behavior looks like) of the behavior, and possibly some antecedent conditions under which the behavior may occur. Then a behavior plan is written up with some antecedent interventions and some consequence interventions. Things to control so maybe the behavior won’t happen. Or things to do after a behavior happens. Plus some replacement behaviors to replace the behaviors that serve the same supposed function. And in the end the behavior is supposed to decrease. If it’s not, then adjustments should be made. They also describe what the behavior looks like and then they HYPOTHESIZE why the behavior may be occurring.
I point out the hypothesize for a reason. With just the indirect and descriptive assessments, you cannot make a causal relationship of why a behavior is occurring. You can only guess. To make the causal relationship, you have to prove it. Prove your hypothesis. And to do that, you need to conduct a functional analysis or FA.
The vast majority of FBA’s do not contain an FA. Cue GASP. Why? Why wouldn’t you want to prove the function of a behavior instead of guessing. That will be a topic for another post 😂 FA’s and the history of FA’s and the ways to conduct them have been the subject of vast research but there is still a lot of myth’s out there and reasons why people don’t conduct them. Strangely enough, I have always done some level of FA. Including with Kreed. Because when I went to doctors, I went armed with the exact reasons for his off the wall behavior so they couldn’t blame “autism”. So that I could use my BCBA speak to combat their Doctor speak and it became a fair fight. I typically won. I once told them, you guys are experts at understanding the body and from what people tell you. Kreed can’t tell you. But his behavior does. And I’m an expert in what his behavior says. These were epic conversations. But I digress.
This is one of the problems I find with our field. People are afraid to go outside their comfort zone. What they have been taught- child presents with behavior, I describe that behavior, then I hypothesize that behavior, then I develop a plan for that behavior and then I see if it works. But they aren’t asking WHY. Why is that behavior happening. It’s more than a description. If I knew why that behavior was happening, so much more can be done. I don’t need to guess. I develop highly individualized plans with concrete steps and strong analysis. So in six years, that former 4 year old, now 10 year old’s behavior plan won’t be including those 4 year old behaviors. And did I mention after this FA, the treatment does not involve restraints or safety equipment. We are not planning for them to engage in those severe high level behaviors. I’m not planning for things to be unsafe. I’m planning for the kids to be in a safe, compassionate place with consent and choice and a feeling of mutual trust between both the client and the therapist.
This is why I’m talking about it being meaningful. Life changing. I’m not about doing the same thing and the same strategies. If a child emits a dangerous behavior after we have done an FA and developed a clear and detailed plan, then we have a meeting. Why. Why did it happen? Where was the breakdown? How did we get to that level and what do we do about it? It’s no longer just a frequency count in a chart.
Now, obviously in our field, we should always be conducting a functional assessment (even without the FA). But not everyone does. Some just take the behavior and begin hammering away at it without even taking a closer look at it. Dr. Hanley further gives an in-depth reason on functional assessments in general:
“There is an equally important humanistic reason for doing so; conducting a functional assessment dignifies the treatment development process by essentially “asking” the person why he or she is engaging in problem behavior prior to developing a treatment. Behavior modification, or programming powerful but arbitrary reinforcers and punishers without first recognizing the unique history of the person being served or the prevailing contingencies he or she is experiencing, is somewhat inconsiderate. It is like saying, “I don’t know why you have been behaving in that extraordinary manner, but it does not matter because I can change your behavior.”
By contrast, a behavior analytic approach, with functional assessment at its core, essentially communicates: “I don’t know why you have been behaving in that extraordinary manner, but I will take some time to find out why and incorporate those factors into all attempts to change your behavior.”
He also gives an equally powerful example:
Imagine that you experienced some temporary muscle paralysis that does not allow you to talk, write, or engage in controlled motor movements. You are now hospitalized and on several medications that have the common side effect of drying out your eyes, nose, skin, and, especially your mouth. Water is viewable on the rolling table, but unattainable due to your lack of dexterity. You learn that if you bang the bed rails with the back of your hands long enough and loud enough, people will come to you and do things for you, like turning the television on or off or fluffing your pillows, or give you things, one of which is the water that you desperately need. Due to its functionality, the banging continues to such an extent that the backs of your hands are bruised and your care providers annoyed. The consulting behavior modifier shows up and recommends a program of contingent restraint with Posey® mitts “to ensure your safety” and access to music and some Skittles when you are not banging. Your problem behavior occurs much less frequently. It doesn’t go away, but your bruises are healing, and the staff is certainly less annoyed with you. Job well done by the behavior modifier? I doubt you think so.
If there were a process available to allow your care providers to know the simple reason why you were hurting yourself and annoying them, wouldn’t you want it employed? Wouldn’t it have been nice to just be able to push a button that requested assistance obtaining water at any given moment (or perhaps simply have access to a long straw!)? The functional assessment process makes these humane and practical outcomes possible.
If you’re a parent reading this and have a child in ABA and it feels like I’m speaking Greek to you, then I would definitely turn to your behavior analyst and ask them what your child’s behavior plan is, and how they developed that plan. At the very minimum they should have conducted indirect and descriptive assessments. Then you can ask if they conducted a functional analysis. If they say well that’s what they did (referencing just the indirect and descriptive) then you might want to educate them that they are missing an important piece of the puzzle.
As a fellow analyst in the field, might I get comments here blasting me for saying all of this? Maybe. But twenty years in the field and watching the directions it has taken, its time we take a long look at ourselves. Can I reduce problem behavior and have I without an FA? Yes. Have I improved the lives of many children without using an FA? Yes. Do I have kids I treated twenty years ago that are thriving adults who are in college or jobs etc? Yes. But could I have done even better back then? Yes. And can I do better now? Yes. So I will do better. I’m not afraid to look at myself or my practice and know I have made mistakes and have not always done what is best. But then you have to strive for more. And we are. And all of our children deserve the best and adding a functional assessment to any behavior assessment is the best and key.
“The literature has shown that descriptive assessments are good at teaching us about the prevalence of the environmental events occurring before and after problem behavior, but that we need to conduct functional analyses to learn about the relevance of those events for the severe problem behavior we are charged with understanding.”
– Dr Greg Hanley
There is so much more I want to say, but trying to keep these short and to the point. I will point out the barriers for why people don’t do functional analysis along with the other parts of an FBA in the next segment. But as an introduction to the changes I’m making within my practice and my company, I wanted to start with the basics. What a functional behavior assessment is, the core components and the component often left out that we are fully implementing. Every client that walks through our doors will be given a functional analysis as part of their intake and treatment plans. We will strive to understand why behaviors are happening and not just defining a topography and making a guess. Does this take more time? On so many fronts? Yes but every client that walks through our doors deserves the respect and compassion for us to ask the question of how they developed this behavior and why. And to have a completely tailored and individual behavior plan to address it.
In the FA’s we have already conducted, we have already seen some of our hypotheses proved and some have been dis-proven and what we “thought” was wrong or incomplete. But now we know why and the analysis has proven the causal relationships so we can better begin to serve our clients.
I know I wrote in a lot of science heavy terms, but I really want to start to discuss these things openly, honestly and deeply about the field I have dedicated my entire adult life to. And the method in which we taught our son Kreed to do so many of the things he was able to do. In many ways, I was already applying many of the things I will be talking about- I just didn’t know others were doing the same thing and questioning in the same ways and frustrated in the same ways.
I have always been transparent about our life in many ways. I didn’t shy away from the difficult moments with Kreed or the extremely amazing moments. I have talked in depth now about child loss and grief and what it has done to me. And now I will be transparent in the way I conduct my practice and talk about ABA in a way that I never have before and as openly. In the comments I will include an article from Dr. Hanley where the above quotes came from and the in-depth talk he gives about FBA’s and FA’s. His work is the cornerstone of the changes we are making. And I thank all of you for all of your kind words both when Kreed was alive and now that’s he’s passed and continuing to follow and comment your love and support for the next stage of my life with my practice. I hope we can continue Kreed’s mission to educate and for us to do better for our kids. So they can all be flying fast on a tube on the river, or be able to take a plane ride to visit grandparents or ride a bike for the first time or go to restaurants or try new foods and enjoy holidays and live their best life without severe behaviors impacting them from living a happier and joyful life.
Kreed chose Joy. And that is what I choose for each child that walks through our doors.