COVID-19 has changed the world, and we have all experienced those changes in a variety of ways. For some of us that meant working, or learning, from home, for others, it meant being distant from loved ones, while others lost jobs and businesses, and many more have lost their lives. After facing all of these hardships we are all looking forward to things returning to some semblance of normal, or open. One thing that seems to be a prerequisite for most countries around the world to re-open fully is an effective vaccine (Guidry et al., 2020). Yet, now that there are 2 vaccines, with Emergency Use Authorization (EUA), in the US, there are growing concerns that many people will refuse, or choose not, to get vaccinated. “Vaccine hesitancy overall has risen so substantially that the World Health Organization (WHO) now considers it a major threat to global health” (Guidry et al., 2020, p. 2). There are several different factors that may make someone hesitant to take the COVID-19 vaccine. Hallsworth and Buttenheim (2020) break those factors down to three categories: rationalization, habituation, and rejection. Rationalization decreases vaccine compliance because people may think that they don’t need the vaccine as they are going to work, and doing many of the same things they did pre-COVID (Hallsworth & Buttenheim, 2020). Asymptomatic cases of COVID-19 also make rationalization more likely, because some people will assume that they had COVID-19 already and therefore don’t need to be immunized, or they will think that any illness they had during the pandemic was COVID-19 (Hallsworth & Buttenheim, 2020). Similarly, Hallsworth and Buttenheim (2020) describe habituation as people just accepting that it is inevitable that they will contract COVID-19, and therefore they have less motivation to get the vaccine or take other precautions. Rejection, however, is where people are resistant to getting a vaccine because after months of lockdowns, quarantine, economic hardship, etc., people may believe that they have already put in the effort to manage the pandemic and don’t see why they should now have to get a vaccine on top of everything else (Hallsworth & Buttenheim, 2020). Another factor that decreases the likelihood of vaccination is concern about the vaccine itself. For some, it is a concern that the whole process of developing the COVID-19 vaccine has been rushed, at the expense of safety, due to political pressure and the desire for a quick fix to the pandemic (Hallsworth & Butteheim, 2020; Schoch-Spana et.al., 2020) Others, who may have been onboard for taking the COVID-19 vaccine as long as it went through the usual process of approval, are now uncertain about taking a vaccine that has received emergency use authorization (EUA) (Cohen, 2020). Even with the EUAs, individuals who reported being more likely to get the vaccine are those who are younger, white, and with fewer barriers to getting the vaccine (Guidry et al., 2020). Overall, individuals of color report being less willing, or likely, to get the COVID-19 vaccine, due to concerns about the vaccine’s effectiveness, and distrust of the government and other agencies that are developing and distributing the vaccine (Cohen, 2020; Guidry et al., 2020; Schoch-Spana, 2020). Concerns about the vaccine’s effectiveness may decrease the number of parents vaccinating their children due to the fact that there have been lower risks associated with COVID-19 for that age group (Hallsworth & Buttenheim, 2020). Similarly, the fact that people in different ethnic groups and geographic locations have been impacted in vastly different ways by COVID-19, could result in a belief in some places or groups that a vaccine is not needed to manage the virus in that location or population (Hallsworth & Buttenheim, 2020). In response to all of those concerns, the Working Group on Readying Populations for COVID-19 with the Johns Hopkins Center for Health Security has several recommendations for the US government and other agencies and policy makers (Schoch-Spana et al., 2020). The first recommendation is to figure out what different communities’ understandings and expectations are by having Congress fund and partner with state and local health agencies, and then make sure that there is a nationwide rollout of promotional information about the COVID-19 vaccine’s benefits, risks, and availability (Schoch-Spana et al., 2020).  Secondly, Schoch-Spana et al. (2020) recommend making the COVID-19 vaccine available for free, and having the federal government and other agencies work with the public and state, and local, health officials to reassess the vaccine allocation plan to ensure that vaccine distribution is seen as fair and equitable to people from different racial, ethnic, and socio-economic backgrounds (p.6). By making the vaccine free and reassessing the distribution plan the government and other agencies could help remove some barriers to getting the vaccine and begin rebuilding Americans’ trust in the government (Schoch-Spana et al., 2020). Aside from making the vaccinations available to all Americans who want to get vaccinated, for no cost, Schoch-Spana et al. (2020) also recommend making the vaccine available in non-medical locations like churches, schools, etc., pairing the distribution of vaccines with other services, and then clearly communicating where, when, and how people can get vaccinated, including any information on how much it will cost, if there is a cost (p. 7). Another way to increase COVID-19 vaccinations is to communicate with local health departments and communities directly, while also making sure to get trusted members of the community to speak positively about the vaccine to effectively address and dispel misinformation that has been released on the vaccine (Schoch-Spana et al., 2020). Additionally, at the federal level, there should be an apolitical panel of experts that, “review, synthesize, and report on best practices for engaging communities in vaccine allocation, deployment, and communication systems to achieve equity, solidarity, and good health outcomes” (Schoch-Spana et al., 2020, p. 8). Similarly, each state should have an oversight committee that takes data on access, allocation, distribution, and understanding and acceptance of the COVID-19 vaccines, to make sure that all groups have equal access to the vaccines (Schoch-Spana et al., 2020).  All of these recommendations could address some of the barriers that make people hesitant to take the COVID-19 vaccines. However, even if the US government implements all of the above recommendations it may not be enough to convince some people to take the COVID-19 vaccines. Large-scale vaccination of the population, along with other preventative measures like social distancing and wearing masks are essential to managing the pandemic and protecting yourself and others in your community from COVID-19 (CDC, 2020). While we have all experienced significant changes to our lives, and in many cases overwhelming losses, due to COVID-19 we now have 2 vaccines that could enable us to return to some semblance of our pre-COVID world.   References:

CDC. (2020, December 21). Benefits of Getting a COVID-19 Vaccine. Retrieved fromhttps://www.cdc.gov/coronavirus/2019-ncov/vaccines/vaccine-benefits.html

Cohen, J. (2020). Here’s how the U.S. could release a COVID-19 vaccine before the election—and why that scares some. Science, online. Retrieved from https://www.sciencemag.org/news/2020/08/here-s-how-us-could-release-covid-19-vaccine-election-and-why-scares-some#

Guidry, J. P. D., Laestadius, L. I., Vraga, E. K., Miller, C. A., Perrin, P. B., Burton, C. W., … Carlyle, K. E. (2020). Willingness to get the COVID-19 vaccine with and without emergency use authorization. American Journal of Infection Control, 1–6. https://doi.org/10.1016/j.ajic.2020.11.018

Hallsworth, M., & Buttenheim, A. (2020). Challenges Facing a COVID-19 Vaccine: A Behavioral Science Perspective. Behavioral Scientist, online. Retrieved from https://behavioralscientist.org/challenges-facing-a-covid-19-vaccine-a-behavioral-science-perspective/

Schoch-Spana, M., Brunson, E., Long, R., Ravi, S., Ruth, A., Trotochaud,M. (2020). on behalf of the Working Group on Readying Populations for COVID-19 Vaccine. The Public’s Role in COVID-19 Vaccination: Planning Recommendations Informed by Design Thinking and the Social, Behavioral, and Communication Sciences. Baltimore, MD: Johns Hopkins Center for Health Security. https://www.centerforhealthsecurity.org/our-work/pubs_archive/pubs-pdfs/2020/200709-The-Publics-Role-in-COVID-19-Vaccination.pdf

Halloween can be a lot of fun, but with the costumes, decorations, new people, transitions, etc., it can be a difficult experience for a lot of individuals with autism and other disabilities. Here are some tips and tricks that might make your holiday go a bit more smoothly.

Before the big day:
On the Day:
After you finish:
Alternatives to trick-or-treating:

As much fun as trick-or-treating can be, it might not be for everyone. It may be more fun for everyone to find another activity altogether.

I hope everyone has a fun and safe Halloween this year. Happy Halloween!

Before reading The ABC’s of Applied Behavior Analysis, it is important that you are aware of two common questions in the field of Applied Behavior Analysis: What does the data show? And,  What has happened before that may be influencing the now?  It is also important to note that the term “instructor” can refer to any of the following: parent, clinician, teacher, Registered Behavior Technician, Instructional Aide, Behavior Analyst, etc.

Applied Behavior Analysis (ABA) is a scientific method that focuses on changing and/or improving socially significant behaviors. It is crucial that the instructor looks at the individual’s Baseline, or current abilities before providing, or changing an intervention. Through the three-term Contingency (A-B-C), instructors can learn what is happening before the behavior (antecedent), what the behavior of concern is (target behavior), and what is following the behavior (consequence).  Learning this information will help to identify if the behavior will likely happen again, or not.

There are seven Dimensions of behavior in Applied Behavior Analysis. These dimensions include generality, effective, technological, applied, conceptually systematic, analytical, and behavioral. These seven dimensions help guide the goals and interventions in an individual treatment plan.

ABA is known for its Errorless teaching method. This method was derived and used to ensure that the individuals we are serving are achieving success in as many opportunities as possible, to increase their motivation of completing a task.

Every action we complete is done with a purpose. In ABA, it is critical to know the Function of a target behavior. The four functions of behavior include: sensory, escape, attention, and tangibles. It is possible that some behaviors have more than one function.

Often you will hear instructors ask one another, “What does the A-B-C data show?” It is through the data collection that Graphs are developed and analyzed. Data analysis of graphs can aid in learning if the targeted outcome is nearing success, or if interventions need to be altered.

Because ABA is an evidence-based approach, it is important that instructors Hypothesize and analyze through A-B-C contingency data, baseline information, and graphs.

There are many different types of schedules of reinforcement. There are two Interval schedules of reinforcement and two Ratio schedules of reinforcement, both looking at fixed or variable. An interval schedule is looking at the amount of time, while a ratio schedule is looking at the number of responses the person does, prior to receiving access to reinforcement.   Just because one schedule of reinforcement was selected, does not mean that will be the schedule of reinforcement this person will be on forever. Keeping an individual on the same schedule of reinforcement, or changing a schedule of reinforcement too quickly, may hinder an individual’s success. Use the data to help determine if a change in the schedule of reinforcement is required. 

Teaching using the errorless teaching procedure is to support the success of the client. It is important that instructors attempt to use the Least to most intrusive prompts when supporting the individuals. This can be through physical gestures, verbal prompting, or pictorial cueing.  

The goal of ABA is to make decisions based on direct observations and data analysis. This helps exclude many Mentalistic theories that behaviors may occur due to inner causes, thoughts, or at random. Instructors are cautioned to Never make conclusions without referring to the data.

It is an instructor’s priority to ensure that the fundamental communication skills are taught. In ABA, Operants, make up the foundation of language and communication development. These verbal operants include: Mand(request), Tact (label), Echoic (repeat), Intraverbal (fill – in phrases), Listener Responses (finding and/or selecting), Motor Imitation (copying), and Visual Perception Match To Sample (following a visual series) are foundations of communication. 

In Applied Behavior Analysis, it is important to identify a person’s Primary and secondary reinforcers. These reinforcers are going to be the most potent, so they are likely to ensure the future change in frequency of the target behavior. It is important to recognize that one reinforcer may not be successful every time. Our interests/needs are constantly changing based on the environment, what we are doing, and what is currently available.

Quality definitions of the behavior(s)you are observing are crucial to ensure accurate data collection. When multiple people can observe and agree when the behavior of interest does or does not occur, your interobserver agreement can be a useful tool to identify the reliability of data. It is important to redefine what the behavior(s) of interest looks like, as this will impact the data and graphs of the intervention.

When facilitating an environment with ABA programs and systems in place, it is crucial that the Rapport between the instructor and individual is positive and strong. This rapport is important when the instructor is seeking Stimulus control, or when a response of interest is occurring more frequently in the presence of the instructor, and not when absent.

There are a variety of Teaching methods that instructors can use to support an individual’s interventions. This may include task analysis, functional communication, video modeling, modeling, and discrete trial training. Each of these teaching methods is used with the errorless teaching procedure, in conjunction with least – to most prompting strategies, to ensure the success of the individual.

It is common to hear “reinforcement” and “punishment” in Applied Behavior Analysis. To better understand these terms, it is important to know that there are different types of reinforcement and punishment. Such as Unconditioned Reinforcement, and Unconditioned Punishment, Conditioned Reinforcement, and Conditioned Punishment. What does all of this mean? Simply, if it is “unconditioned” these are things that we are born with (e.g., feeling starved vs. full, regulated body temperatures vs. extremely hot or cold, hydrated vs. extreme thirst, etc.). If something is “conditioned” this means that the individual has learned what this will get them, or what they want to avoid.  Reinforcement is effective when the behavior occurs again in the future. Punishment is effective when behavior is not likely going to occur again in the future.  

When identifying an effective stimulus, it is important to consider the Value – altering effects and the behavior-altering effects. If you are interested in increasing or decreasing the effectiveness of a reinforcer, you would consider the value-altering effects.  If you are interested in altering the frequency/ intensity/ or timing of the behavior, you would consider the behavior-altering effects.

While the questions of “When do I reinforce?”, “‘X’ is not going away, why not?”, or “You sure this is the best method?” are often heard, remember, if there is Zero data, then there can be no official conclusion if an intervention was or was not working.

Keywords: ABA, Data, Analysis, Stimulus

References:

Safety–Care core curriculum: https://qbs.com/safety-care/

https://www.behaviorbabe.com/acronymsandterms.htm

http://theautismhelper.com/wp-content/uploads/2015/09/ABA-101-Handouts-The-Autism-Helper.pdf

https://medium.com/@carlylecenter/7-dimensions-of-applied-behavior-analysis-5eb85128cf0a

 
Why Define Behavior

A critical piece to every behavior plan or behavior intervention is the “target behavior”. In the majority of cases, this is the behavior of concern that the intervention is meant to decrease and it will often be paired with a functionally equivalent replacement behavior. For example, a target behavior labeled “Hits” may be defined as “forcefully swings an open or closed fist in the direction of her head or chin, swings objects in the direction of her head/chin, or swings her head in the direction of a wall or desk with or without making contact” (pulled from an actual behavior support plan referenced in the 2013 article by Smith, Lambert, & Moore). In contrast to this, a replacement behavior labeled “Places” may be defined as “gently places open palms on head or chin, places open palms on objects, or gently lowers and places head against object”.

In both examples, the target behavior and the replacement behavior are described such that a member of the team of interveners (staff, family, etc.) would be likely to identify the behavior as it is occurring such that it can be counted for data collection and responded to with a consequence procedure. With this in mind, we can generally state that we define behaviors so that interveners can count them and use them as a cue for when to implement a behavior change procedure.

The Trouble with Defining Behavior

Now that we’ve agreed on a general “why”, let’s revisit the target behavior labeled “Hits” used above. It reads, “forcefully swings an open or closed fist in the direction of her head or chin, swings objects in the direction of her head/chin, or swings her head in the direction of a wall or desk with or without making contact”. Take a moment and envision this behavior. Maybe even forcefully swing your arm a time or two being careful not to strike a person or object in your vicinity. Now take another moment and imagine someone is watching you as you swing your arm. Does that person also believe the speed of the arm was “forceful”? Does the arc of the arm fall within the definition of a “swing” or is it more of a “whirl”? Was the swing in the “direction” of the head or more towards the shoulder?

Here we see how a behavioral definition, which was pretty clear just a moment ago, can be rife with uncertainty. This is troublesome even when there is just one intervener who is unsure if a behavior “counts”. However, we often instill teams of interveners to measure behavior and intervene. If each person conceptualizes the target behavior differently, then how can we be sure it is counted reliably and accurately? Are there strategies to increase the likelihood that each subjective experience of the target behavior aligns with the actual event? If so, how can these increase agreement, decrease confusion, and ultimately improve treatment fidelity?

Considerations for Defining Behavior

While no source has established the “best” way to define target behaviors for intervention, there are several factors deemed valuable to the process. Several of these are reviewed below.

  1. Present Tense, Active Voice – Use the present tense and an active voice form of a verb in your behavioral definition. Verbs that demonstrate action on an object ending in “s” usually meet this criteria. “Touches head”, “Throws ball”, “Sits bottom”, “Raises hand”, “Drops body”, etc. For those with experience with Celeration Charting and Precision Teaching, these may seem familiar.
  2. Remove or Limit Adverbs – Adverbs can be great qualifiers in some behavior plans, especially ones that are specifically intervening on the intensity of a behavior. However, if intensity is not a qualifier, adverbs can create confusion. For example, “Quickly raises hand” introduces confusion to the observer. They may ask, “Did that count as quick enough?” when collecting data. Remove the confusion by removing the adverb. “Raises hand” is a fine target behavior without extra qualifiers.
  3. Develop Exemplars – Within your team, demonstrate exactly what counts and does not count as an instance of the behavior and review these with all interveners. This is especially useful if the behavior may look different across various contexts or when adverbs cannot be removed from the definition. It is also especially useful when the behavior may not match the words. Even the phrase “raises hand” can lead to some confusion. Was the hand “high” enough? Was the bend to the arm within an “acceptable range”? Does it count if “both” hands are raised at the same time? Having staff review and observe various forms of the behavior can significantly improve detection and, therefore, increase both the quality of the data and correct implementation of the behavior change intervention.
  4. Update Definitions regularly – It should come as no surprise that behaviors change over time. In most cases, the behavior is gradually shaped such that the most effective version of the response is selected more and more frequently. Because of this, we should expect changes in the behavior over time and update our definitions accordingly.
  5. Build Directly into Interventions – Incorporating these pieces from the outset of designing an intervention can be quite helpful when training an intervener. While this can take many forms, consider the ABC Chart format below:
Antecedent Behavior Consequence Schedule
Teacher asks question Student raises hand Student earns sticker FR3 – Every third-hand raise = sticker
Teacher asks question Student shouts answer Staff reviews raising hand FR1 – Every shout = Staff review
Notes:

– FR3 refers to a Fixed-Ratio schedule with delivery on the third response.

– FR1 refers to a Continuous schedule with delivery on every response.

Wrap-up

Again, it should be repeated that no “best” way to define a behavior has been established. In fact, if such a best way existed, the field as a whole would be in a very different place. The suggestions and discussion above offer one starting point to a larger discussion on defining behaviors. Hopefully, they are also useful in some way to you, the reader, regarding the creation of behavioral definitions, treatment planning, and intervention.

Until we meet again, happy definition writing!

Disclaimer:

Please note that the strategies and items discussed here do not constitute clinical advice and should not be used in place of treatment interventions developed by clinical professionals and multidisciplinary teams in your place of work. While some of the suggestions here may be incorporated into a well-designed treatment package, every treatment should be individualized to address the needs of the individual served.

References

Smith, G. D., Lambert, J. V., Moore, Z. (2013). Behavior description affects accuracy and reliability. The Journal of General Psychology, 140(4), 269-281.

Running a Safety-Care class smoothly can be a tough task, especially when you’re a new trainer. There can be numerous obstacles such as time restraints, trainees that are not following class rules, having trouble with competencies, or are just really nervous about the class. As a trainer, it is our responsibility to be prepared to handle those tough situations, set up the class for success, and manage time effectively.

Here are some general tips that should help you run your class, a little smoother:

  1. Be prepared.
    • a. Read through Chapter 8 before you teach your class. This is the chapter on teaching Safety-Care and has a lot of useful information for trainers.
    • b. If there’s specific physical competencies or variations that you don’t remember how to perform, log into Trainer Connect and watch videos of the skills.
      • i. While you’re reviewing the material, anticipate questions your staff will ask, so that you’re ready with answers.
    • c. Read trainer notes on the right side of the Trainer Manual, highlight, make notes, or cross off ones that don’t apply to your setting.
    • d. I used to be very nervous presenting in front of people, from personal experience I can say that your nervousness will go down significantly if you practice ahead of time (especially sections that you’re not super comfortable with).
  2. Verbal competencies (DR and DE)
    • a. Trainees tend to have trouble with verbal competencies (Differential Reinforcement, and De-escalation) so make sure you review these and are familiar with the common errors (found in the trainer notes).
    • b. One way we can help trainees succeed is by setting up demonstrations for success. Start with simple scenarios and don’t identify too many variables for your demonstrations. As your staff show that they’re comfortable with the verbal comps you can increase complexity.
    • c. Although the purpose of the de-escalation strategies is for us to be so fluent that we can use them interchangeably, when first teaching a competency don’t set up demonstrations with all strategies in it. Remember to start simple, isolate each strategy and teach them separately. As your staff become fluent in each strategy, you can have them use multiple strategies in scenarios.
    • d. Emphasize the differences in each schedule/strategy of DR and DE so that your staff don’t end up getting them confused.
    • e. Come up with scenarios that are relevant, so the skills in training generalize to their jobs. Try to notice everyday situations where a schedule of DR, or a DE strategy would’ve been helpful, then use similar scenarios when teaching verbal comps.
  3. Use Role-plays to your advantage.
    • a. The first thing we should acknowledge is how nervous people are for Role-plays. Take that into account when running your role-plays. Although a lot of people don’t like role-plays, everyone learns a lot from these, especially if the role-plays are relevant to where your staff work.
    • b. There are many ways to come up with role-play scenarios, one strategy is to be part of debriefing meetings then take notes on skills that your staff seem need more practice with. Use similar situations to what they’re likely to see on the job. You can also ask your staff: what situations have you encountered where you weren’t sure how to respond?
    • c. Stop a role-play when needed. Not only for serious mistakes, but when you think a discussion would be helpful, when your staff look confused, or overwhelmed. After a brief discussion, repeat that part of the role-play so that your staff can implement your suggestions.
    • d. Always go over the role-play rules in chapter 7. As a trainer, you’re acting as the individual in the role-play so you have more control over how the role-play will go.
  4. Time
    • a. You have so much to cover in your class, so time-management is key, you don’t want to run out of time, or not meet your minimum time for the class.
    • b. If this is your first time teaching Safety-Care, I recommend you allow yourself a couple extra hours to give you some wiggle room. No one will be upset if you let them out early while still meeting your minimum training times.
    • c. Use the initial and recert class schedules in chapter 8 to make sure that you’re on track to finish on time.
    • d. Watch out for very specific questions about certain individuals, behavior plans etc. If you can’t bring it back to Safety-Care, then that question is probably better answered after class or during a break. Remember you have a lot to cover!
    • e. The more you teach/practice the faster you’ll be able to go through lecture sections of the curriculum.
    • f. Sometimes you’ll have a trainee that has tried a competency multiple times and doesn’t seem to be improving. Rather than keeping them in the spotlight, have them come see you during a break and pass their competency 1:1. This way, you’re saving class time, and not embarrassing someone that can’t perform with an audience.
      • i. Another strategy is to have that trainee go to the back of the line, while you’re passing others’ competencies, so they can observe more demonstrations of the skill. Remember that no one was born with these skills, and some will have more trouble than others.
    • g. One of the best things about Safety-Care is how you can abbreviate the curriculum rather than teaching the whole thing. Refer to compliance standards (page 7-9) for abbreviation standards.
  5. Practice throughout the year
    • a. You have a lot of flexibility when it comes to practicing with your staff. Because you’re only practicing skills with staff that are currently certified in Safety-Care, you don’t have to pass competencies again. Rather, pick certain skills that your staff frequently use, have trouble with, or could use a little practice on.
    • b. Take advantage of the “technique of the week” calendar.
    • c. Practice of skills can be done for any amount of time, with any number of staff. It can be a quick review of Safety Habits, a more prolonged practice of physical skills, or additional role-plays.
    • d. Practicing throughout the year will also help your staff be more fluent when it comes time for their Recertification class, which will make your class run faster and smoother.

Running Safety-Care class requires multiple skills from time-management to setting up demonstrations for success. If you’re prepared, you’ll feel more confident teaching the class. There’s a reason why trainers have to get 24hrs of teaching per year, because the more you teach the more comfortable you’ll feel, and your classes will go more smoothly. Plan out your demonstrations, scenarios, and role-plays ahead of time so you don’t have to come up with those on the spot. Watch the time so you stay on track and don’t end up having to rush at the end. Don’t forget that you can always contact QBS if you need help running your class or setting up practice sessions. Finally, remember to have fun! Everyone learns better when they’re engaged.

 

Keywords: time-management, safety-care training, setting up training, teaching Safety-Care

DE, or De-Escalation, is a process that involves the use of the Help, Prompt, and Wait strategies to help someone go from crisis to calm. While both the Prompt and Wait strategies can be used at any point on the staircase, the Help strategy should only be used at the bottom of the staircase. However, since there is no set sequence, it can be hard to know which strategy to start with and when to switch from one strategy to the next. The rest of this blog will break down each of the three Safety-Care De-Escalation strategies and when you should start with, or move on from, that strategy.

In Safety-Care, the first de-escalation strategy you learn about is the Help strategy. Help is a de-escalation strategy that focuses on having the person communicate what they need or want, instead of engaging in challenging behavior. This strategy can be done by having someone make a specific request like, “I want water.” Or, you could give the person 2-3 acceptable choices and have them make a selection from the options you provided. Another way to use the Help strategy involves asking the person an open-ended question like, “How can I help you?”. All three of these options have the person use some type of communication to express a need or want.

Therefore, you would use the Help strategy when you think the person is trying to get access to or avoid, a person, place, or thing. The exception to this would be if the person wants something that is unavailable. If you know the person wants something that is not available, then you would switch to the Prompt or Wait strategies instead. Once the person has escalated to the upper part of the staircase, the Help strategy would no longer be as effective. The reasons for this are that people are unable to communicate effectively when at the top of the staircase, providing access to something requested would result in reinforcement and you would not want to reinforce crisis behavior, and at the top of the staircase, the person is unlikely to ask for things that are available. You would also switch to the Prompt or Wait strategies if the individual becomes more agitated when you attempt to use the Help strategy.

While the Help strategy is all about communication, the Prompt strategy is about giving the person clear instructions to engage in safer behavior. The two types of behavior that you can prompt the person to engage in are incompatible and high-probability behavior. Behaviors are incompatible if they can’t happen at the same time, while high-probability behaviors are things the person is likely to do. Sitting is a behavior that is incompatible with pacing. Taking a deep breath, counting, or answering simple questions are all examples of high-probability behaviors. Prompts can be given verbally or nonverbally, with gestures, signs, or in writing. The Prompt strategy is the ideal place to start if the person is likely to follow directions, or if the Help strategy has not been successful, or caused the person to become more agitated.

However, if the individual is unlikely to follow prompts that are given then you would switch to the Help or Wait strategies. Conversely, if the person has become more compliant after several prompts, you may switch from the Prompt to the Help strategy to continue to guide the person down the staircase. Also, if the Prompt strategy has made the person more agitated then you should stop prompting and switch to the Wait strategy.

WAIT is an acronym that reminds us what to do during the Wait strategy, and it stands for “Why Am I Talking?”. During the Wait strategy, staff and others should not talk with, touch, or stare at the agitated individual. This strategy is often more successful if you clear the audience, move the person to a less stimulating location, or keep other staff and peers from accidentally engaging with the agitated person. While using the Wait strategy, staff should be clearing dangerous objects and substances, removing vulnerable peers, and always monitoring for the individual’s safety. Wait is a wonderful strategy to start with when you want to remove all external reinforcement, the person would benefit from being given time and space to de-escalate, nothing else is working, or the Prompt and Help strategies have made the person more agitated.

Although this strategy is a great place to start when Help and Prompt have been unsuccessful, you can’t stay in Wait forever. At some point, when the individual has shown some sign of de-escalation or taken even a small step down the staircase, then staff should attempt to switch back to using either the Help or Prompt strategies, depending on which strategy they feel would be more effective in the moment.

Knowing your individuals will make the use of all three De-Escalation strategies more effective and help give staff a better idea of when to use one strategy versus another. Help, Prompt, and Wait can all be effective and should be used in a fluent manner where staff switch from one strategy to the next, in response to the agitated individual’s behavior. Remember that there is no sequence and you should start with whichever strategy will be most effective in that moment, with that person.

References: Safety-Care Manual v. 6

Leisure skill training is an important, yet, often overlooked area of development for the individuals we work with. Sometimes we believe that leisure engagement is not a skill we teach. This is a myth. Or we allow an individual to engage with an activity in a nonfunctional way and call that leisure. Again, a myth. Moreover, we may think that teaching one leisure activity is enough. Another myth. Like most complex behavior chains, leisure needs to be developed through skill acquisition training and adequate planning. A rich leisure repertoire consists of multiple age-appropriate, goal-oriented activities that are preferred. Developing a rich leisure repertoire has multiple benefits supported by research:
  1. Protects human rights: Leisure is an expression of freedom that is categorized as an inalienable human right. The Universal Declaration of Human Rights, 1948, states that “Everyone has the right to rest and leisure”. Additionally, the Individuals with Disabilities Education Act, 2004, further protects this right by insisting that leisure and recreation should be discussed within the IEP.
  2. Enhances quality of life: Happiness is a distinctive feature of quality of life. Research by Lancioni and colleagues (2005) and Parsons and colleagues (2012) have demonstrated that the indices of happiness are observed when an individual engages in leisure. Moreover, studies have shown a positive correlation between active leisure and life satisfaction (Harper & Heal, 1993).
  3. Reduces challenging behavior: We all have heard the phrase, “Idle hands are the devil’s plaything.” Leisure activities engage those idle hands, gives them something to do. Research demonstrates by merely providing leisure items, challenging behavior decreases (Fisher et al, 1992; Lindberg et al, 2003).
  4. Promotes social interaction: Leisure is an opportunity to interact with others and share common experiences. It improves peer acceptance and facilitates improved family relations (Dodd et al., 2009).
  5. An effective context for learning: Leisure provides a context for incidental teaching, in which the individual’s natural motivations guide the learning process (Hart & Risley, 1975).
  6. Improves health: Higher participation in any leisure is correlated with low blood pressure, cortisol level, waist circumference, and BMI (Pressman et al., 2009).

With all of these wonderful benefits, it’s important to spend time identifying leisure skills that an individual can access across different environments (parks, residence, social gatherings, etc.) and make sure the materials are practical and easy to access or replace. Plan structured teaching times that increase an individual’s fluency with each step of the activity. Build on activities they may already prefer and assess and increase preference before concluding leisure skill-building.

Please don’t hesitate to reach out about leisure skill training. My email is fzaidi@qbs.com.

Please watch my Behavior Brief on ‘Promoting Leisure Engagement During Social Distancing”  for more information about leisure engagement.

References:

Dattillo, J., Schleien, S. J. (1994). Understanding leisure service for individuals with mental retardation. Mental Retartation (now called Intellectual and Developmental Disabilities), 32(1), 53-59.

Dodd, D. C. H., Zabriskie, R. B., Widmer, M. A., & Eggett, D. (2009). Contributions of family leisure to family functioning among families that include children with developmental disabilities. Journal of Leisure Research, 41, 261-286. 10.1080/00222216.2009.11950169

Fisher, W., Piazza, C. C., Bowman, L. G., Hagopian, L. P., Owens, J. C., & Slevin, I. (1992). A comparison of two approaches for identifying reinforcers for persons with severe and profound disabilities. Journal of applied behavior analysis, 25(2), 491–498. doi:10.1901/jaba.1992.25-491

Hart, B., & Risley, T. R. (1975). Incidental teaching of language in the preschool. Journal of applied behavior analysis, 8(4), 411–420. https://doi.org/10.1901/jaba.1975.8-411

Lancioni, G & Singh, Nirbhay & F O’Reilly, M & Oliva, D & Basili, Giancarlo. (2005). An overview of research on increasing indices of happiness of people with severe/profound and multiple disabilities. Disability and rehabilitation. 27. 83-93. 10.1080/09638280400007406.

Lancioni, G & Singh, Nirbhay & F O’Reilly, M & Oliva, D & Basili, Giancarlo. (2005). An overview of research on increasing indices of happiness of people with severe/profound and multiple disabilities. Disability and rehabilitation. 27. 83-93. 10.1080/09638280400007406.

Parsons, M. B., Reid, D. H., Bentley, E., Inman, A., & Lattimore, L. P. (2012). Identifying Indices of Happiness and Unhappiness Among Adults With Autism: Potential Targets for Behavioral Assessment and Intervention. Behavior Analysis in Practice, 5(1), 15–25. http://doi.org/10.1007/BF03391814

We all know that the cry of an infant means they are communicating their wants and needs. Since the infant is not born with the knowledge or ability to speak, it engages in crying behavior to communicate. In reaching developmental milestones, infants learn new and effective ways to communicate and as a result, crying behavior decreases. Over time and across experiences, the individual learns that using their words results in gaining access to wants and needs.

This process is referred to as Functional Communication Training (FCT). In 1985, Edward G. Carr and V. Mark Durand published the first study using FCT which documented how effective it could be for reducing and replacing challenging behaviors with socially appropriate behaviors (i.e., communication responses).

The key with FCT is to identify the function of the challenging behavior. What this means is, we are looking to identify what the individual is looking to access. For some individuals, the challenging behaviors they engage in communicates their wants and needs (like the crying infant example). Applied Behavior Analytic research shows that individuals engage in challenging behaviors to either gain attention (from another person), gain access to an item, or escape something such as a task, person, or location. Sometimes, individuals engage in challenging behaviors because it makes them “feel good” and this is a type of “sensory” function.

Identifying the function of challenging behaviors allows the educator to target and teach specific communication responses that will eventually replace challenging behaviors. By teaching the learner to communicate more appropriately to get their needs met, there is less need to engage in challenging behaviors. This idea of communication through behaviors can be applied across a variety of individuals and scenarios.

Since the publication of the 1985 study by Carr and Durand, FCT has developed into an established and effective evidence-based treatment for improving challenging behavior and teaching appropriate and effective communication skills. Our Safety Care curriculum utilized this type of research in order to develop effective de-escalation strategies for managing challenging behaviors.

 

Sources:

Carr, E. G., & Durand, V. M. (1985). Reducing behavior problems through functional communication training. Journal of Applied Behavior Analysis, 18(2), 111-126.

Some Habit History

Habits, habit behaviors, or habit disorders are often defined as repetitive, body-focused behaviors that serve no adaptive function and are often unwanted due to the stress or functional impairment they cause (Hansen, Tishelman, Hawking, & Doepke, 1990; Bate, Malouff, Thorsteinsson, & Bhullar, 2011). Such behaviors include: nail-biting, hair pulling (trichotillomania), skin picking, and teeth grinding (Miltenberger, Fuqua, & Woods, 1998); though other behavior such as saying “um” during pauses while speaking in public can be addressed within the same “habit” framework (Mancuso & Miltenberger, 2016). Prior to 1973, leading treatments of habit disorders included psychotherapy, drug interventions, shock-aversion therapy, and negative practice (Azrin & Nunn, 1973). These treatments vary in effectiveness and, in some cases, were not the most humane forms of behavioral intervention as they relied on punishment procedures. As such, several of these treatment approaches would not be used today. Fortunately, an effective approach to treating habits was developed and published by Azrin and Nunn in 1973.

Steps to Habit Change

Azrin and Nunn (1973) built on the work of Butcher (1968) who argued that nervous habits are maintained through operant reinforcement. In conceptualizing habits this way, Azrin and Nunn developed a five step treatment approach and recruited 12 participants to see if it worked. The intervention took place over  The results were astounding. Of the 12 participants, 10 of them displayed an average of zero habit behaviors three weeks after treatment had concluded. The seven participants who remained in the study for all follow-up activities collectively showed a 99% reduction in habit behavior at five months post treatment. The procedures used by Azrin and Nunn (1973) are described as steps below and can be utilized in your own life.

  1. Self-Monitoring: To begin, the individual changing the habit selects a way of counting how often the habit behavior is occurring. This could be an exact count of each time it is happening or a statement regarding the percentage of time each day that the habit behavior is occurring. Various recording strategies can be used depending on individual preference.
  2. Awareness Training: In this step, the individual changing the habit systematically increases their ability to detect when the behavior is occurring. Several separate systems for this are described by Azrin and Nunn (1973):
    • a.) Response Description Procedure: The individual is asked to describe in detail, perhaps using a mirror if necessary, each part of the behavior while engaging in the behavior; attaching the language to the movements.
    • b.) Response Detection Procedure: A third party informs the individual when the behavior is occurring and assists the individual in recognizing the behavior (e.g. a third party alerts the individual when their hand is in their mouth).
    • c.) Early Warning Procedure: The individual practices detecting the earliest sign of the habit behavior (e.g. when a nail biter first begins to move the hand closer to their mouth).
    • d.) Competing Response Practice: The individual is asked to tense the muscles involved in the habit behavior and, in doing so, consequently stop the habit behavior from occurring (e.g. as the individual moves the fingertips towards the mouth, the individual instead tenses the muscles along the length of the arm stopping the motion towards the mouth).
    • e.) Situation Awareness Training: The individual is asked to recall all situations, persons, and places where the habit has occurred or is likely to occur and what the habit looks like in that setting (e.g. the individual describes how they put their head down to bite their nails discreetly in a public setting).
  3. Competing Response Practice: This builds on option “d” in Step 2. In this step, the individual selects a response that is incompatible with the habit behavior and includes all or some of the following characteristics:
    • a.) The movement is opposite that of the habit behavior (e.g. moving the hand away from the mouth rather than towards for nail-biting).
    • b.) The movement can be maintained for several minutes (e.g. holding an object tightly or pressing the hand into the leg rather than having it near the mouth for nail-biting).
    • c.) The movement results in muscles tensing and increasing awareness of the muscles involved in the movement (e.g. clenching fist of the hand that has been moved away from the mouth for nail-biting).
    • d.) The movement is inconspicuous in a public setting and allows for continued engagement in daily activities (e.g. the clenched fist of the hand away from the mouth is placed in the pocket of the individual for nail-biting).
    • e.) The muscles involved in the movement are strengthened through some level of exercise (e.g. grip strengthening exercises for nail-biting).
    • f.) The individual should engage in the competing behavior for three minutes every time s/he experiences the temptation to engage in the habit behavior and when s/he catches him-/herself engaging in the habit behavior. The Azrin and Nunn (1973) article provide some specific examples of competing behaviors for various nervous tics on pages 624-625.
  4. Habit Control Motivation: This step involves several strategies to increase the individual’s motivation to actively engage in the Awareness and Competing Response pieces of the intervention. These strategies may be implemented by the individual or by a third party involved in the intervention and include:
    • a.) Habit Inconvenience Review: In this strategy, the individual reviews any embarrassment or inconveniences that that habit has resulted in. This strengthens the motivation to avoid embarrassment or inconvenience by either not engaging in the habit behavior or by engaging in the competing behavior.
    • b.) Social Support Procedure: In this strategy, family and friends of the individual strengthen the motivation by 1.) commenting favorably on efforts when habit-free periods are noted, 2.) offering reminders to “practice your exercises” when habits are overlooked by the individual, 3.) having a third party offer praise for the individual’s efforts at inhibiting habits.
    • c.) Special Procedures with Children who are not motivated: Parents either physically guided their children through the competing behaviors upon observing a habit behavior or instructed the child to practice the competing behavior in a bedroom if they failed to self-initiate the competing behavior.
  5. Generalization Training: This step involves practicing the awareness and competing behavior steps in approximations of the natural settings that the individual spends time in. In some cases, these approximations only need to be imagined. Again, several procedures are available, including:
    • a.) Symbolic Rehearsal Procedure: In this strategy, the individual imagines common and habit-eliciting settings and that s/he has just engaged in the start of a habit behavior. The individual then engages in the appropriate competing response as if s/he had actually displayed the habit behavior.
    • b.) Additional Practice (Procedure not specified): In this strategy, the individual discusses topics that do not relate to habit behaviors with a third party, simulating an everyday conversation. When the individual begins to initiate a habit behavior, they will detect this and engage in the competing response. The third party is a confederate and will offer a subtle sign to the participant if s/he does not engage in the competing response after initiating the habit behavior.

Wrap-up

Currently, the field of Applied Behavior Analysis (ABA) is often considered synonymous with interventions related to autism and intellectual disabilities. Habit Reversal Training deviates from this common association and demonstrates the application of ABA outside of “traditional” populations (Rapp et al., 1998; Twohig & Woods, 2001). The application of Habit Reversal Training also extends across countries and languages such as seen in the work on Nail Biting by Singal and Daulatabad (2017) in India. Finally, it is recognized as a competitive treatment for habit behaviors and is acknowledged as such by practitioners outside of the field of ABA (see Schumer, Bartley, and Bloch’s article in the Journal of Clinical Psychopharmacology (2016) comparing the effects of pharmacological and behavioral interventions).

Disclaimer: While the strategies discussed above can be adapted and implemented in a self-monitoring approach, the use of “third-party” throughout the Blog references a clinician in the original study by Azrin and Nunn (1973). While the information provided offers a framework for decreasing habit behaviors, working with a professional skilled in habit reversal and behavior change is recommended.

Let’s make a habit of continued dialogue between QBS and you. See you again soon!

References

Azrin, N. H., & Nunn, R. G. (1973). Habit-reversal: A method of eliminating nervous habits and tics. Behavior Research and Therapy, 11, 619-628.

Bate, K. S., Malouff, J. M., Thosteinsson, E. T., & Bhullar, N. (2011). The efficacy of habit reversal therapy for tics, habit disorders, and stuttering: A meta-analytic review. Clinical Psychology Review, 31, 865-871.

Bucher, B. D. (1968). A pocket-portable shock device with application to nail biting. Behavior Research and Therapy, 6, 389-392.

Hansen, D. J., Tishelman, A. C., Hawking, R. P., & Doepke, K. J. (1990). Habits with potential as disorders: Prevalence, severity, and other characteristics among college students. Behavior Modification, 14, 66-80.

Mancuso, C. & Miltenberger, R. G. (2016). Using habit reversal to decrease filled pauses in public speaking. Journal of Applied Behavior Analysis, 49(1), 188-192.

Miltenberger, R. G., Fuqua, R. W., & Woods, D. W. (1998). Applying behavior analysis to clinical problems: Review and analysis of habit reversal. Journal of Applied Behavior Analysis, 31(3), 447-469.

Rapp, J. T., Miltenberger, R. G., Long, E. S., Elliott, A. J., & Lumley, W. A. (1998). Simplified habit reversal treatment for chronic hair pulling in three adolescents: A clinical replication with direct observation. Journal of Applied Behavior Analysis, 31(2), 299-302.

Schumer, M. C., Bartley, C. A., & Bloch, M. H. (2016). Systematic review of pharmacological and behavioral treatments for skin picking disorder. Journal of Clinical Psychopharmacology, 36(2), 147-152.

Singal, A. & Daulatabad, D. (2017). Nail tic disorders: Manifestations, pathogenesis and management. Indian journal of Dermatology, Venereology, and Leprology, 87(1), 19-26.

Twohig, M. P. & Woods, D. W. (2001). Habit reversal as a treatment for chronic skin picking in typically developing adult male siblings. Journal of Applied Behavior Analysis, 34(2), 217-220.

Keywords: habit disorders, habit reversal training, hair pulling, skin picking, self-monitoring

 

  Safety-Care trainers are expected to do 24 hours of trainer per year. If they fail to do so, they are required to participate in an additional online supplemental webinar with a master trainer. This supplemental has a separate fee and must be completed either before recertification or within 1 month following their recertification class. If a trainer fails to complete a supplemental training, they may not train unless they are co-training with a fully certified Safety-Care trainer. So, you may be asking yourself… how do I make sure I get 24 hours in?! Many trainers who do not meet their 24-hour requirement might actually have met the requirement but do not know all of the activities that count towards their hour requirement. Below is a list of activities for trainers to help ensure you get your hours in before your annual recertification. In summary, any time a trainer spends teaching initial or recertification classes in the core curriculum or advanced modules, as well as any time conducting review, practice, or remediation sessions with staff who are currently certified in Safety-Care counts toward the annual training hours. If you work for a small organization, don’t conduct many trainings per year, or just forget to log in hours outside of training, use these tips to ensure you meet the 24-hour requirement. If you find yourself unsure if a specific situation counts towards your hours, feel free to reach out to us here at QBS, we’d be happy to help!

Summary of Resources QBS offers its customers

Here at QBS, we want to support our trainers and specialists as much as we can. Below is a collective list of different resources we provide for both trainers and specialists.
Telephone Support/Email Support
Call our office at (855) 727-6246 weekdays between 9 am-5 pm Eastern time (or leave a message) and ask to set up a time to speak with a Safety-Care master trainer. You can also send an email to info@qbs.com. Describe your question or concern in the body of the email and we’ll get back to you as soon as possible. Feel to reach out for anything from trainer connect issues, compliance standards questions, procedure questions, to advice on specific escalated situations.
Live Chat Support
Have a quick question while browsing our website? You’re in luck! The live chat you see as your scrolling our website sends your question right to an employee at QBS. We will be able to answer your question or transfer you to a person who can. Easy as that!
Social Media
We can be found on social media on Facebook, Instagram, Twitter, LinkedIn, and YouTube. We often provide periodic tips, suggestions, new blog topics, and other information over social media. Our YouTube (QBS, Inc.) provides our customers with an abundance of information involving safety care and other interesting topics.
Blog Posts
We post various blogs post on various topics like community, crisis prevention, among many others! These posts are for our customers to have resources provided to them on a monthly or weekly basis.
COVID-19
We are continuously updating our COVID-19 regulations available on our website. These standards include information on, how to conduct remote trainings, the current grace period, how to maintain skills during this time, how to modify in-person trainings, and FAQs.
Trainer Connect
Trainers with access to trainer connect have an abundance of resources at their fingertips. Trainer Connect is where trainers record their trainings. It also allows you to pull reports of specialists and trainers which shows when each person’s certification is expiring. There are also videos available of all procedures in the Safety-Care curriculums. These videos do not have any audio and are only a few seconds in duration. Another resource on Trainer Connect is recordings of previous Safety-Care Live for Trainer webinars.
Consultation
We also offer expert paid consultation services to organizations seeking assistance in a number of areas, including the adaptation of the Safety-Care curriculum to specific behavioral challenges or clinical settings. If you are interested or would like more information please email  info@qbs.com or call our office at (855) 727-6246.

With the world shutting down due to a global pandemic last year, many families and service providers of individuals with developmental disabilities in the United States have been learning to navigate the new world of modern technology in order to continue providing and receiving care. Distance learning and telehealth sessions have become a new normal for many of us. Despite potential challenges, did we learn anything new about using telehealth to provide care to the individuals we serve? Are these lessons important for the larger community beyond the United States?

I think the answers and yes and yes. 

Using telehealth format for ABA service delivery.

Behavior analysis is one of the widely accepted approaches for the treatment of challenging behaviors associated with autism spectrum disorder and other developmental disabilities (CDC website). We will discuss using telehealth to deliver specifically Applied Behavior Analysis (ABA) services in this section and highlight some of the most recent available research.

One study was conducted in California over the course of several months after the shelter-in-place order was announced (Pollard et. al, 2021). ABA service recipients who wanted to continue receiving services were left with 2 choices: telehealth with a technician or telehealth caregiver training with direct caregiver implementation. There were 17 participants in total. According to Pollard et. al, “Participants continued to access similar dosage of treatment hours per week in spite of the treatment model transition and maintained or improved correct independent responding across all targets from in-person treatment to telehealth treatment” (p. 87). There was a 5% average improvement across targets for the participants, and these findings provide initial evidence that some clients with autism benefit from technician-delivered telehealth services.

Another recent study was conducted in Texas, where a team of researchers used telehealth to coach parents in conducting brief functional analyses to identify the function of their children’s challenging behaviors and implementing initial treatment (Gerow et. al, 2021). 7 families participated, and additional evaluations by trained providers supported the results of the functional analyses conducted by parents in 5 cases, with the other 2 participants not engaging in enough observable instances of challenging behavior to identify the function and continue treatment. This indicates that using telehealth to coach caregivers in implementing services may be an effective method for assessing and treating challenging behavior.

Other research on using telehealth for service delivery and training is available, including a few intercontinental studies like Barkaia et. al, 2017. This is unique because:

  1. Coaching to technicians was provided in English and Georgian while all services to participants were delivered in Georgian
  2. The study outcomes involve significant improvement of the technicians’ implementation skills after participating in telehealth coaching with certified behavior analysts in addition to measurable improvements on targets demonstrated by participants.

It is early to draw any conclusions, but there’s definitely more evidence available after the last year that supports the potential effectiveness of the telehealth model of delivering ABA services and training technicians and caregivers.

Why is it important to the world?

Behavior-analytic approach to treating challenging behaviors and finding functional alternatives primarily developed and evolved in the United States. ABA-based services in their modern form quickly became known as one of the effective approaches worldwide (thanks in part to modern technology), but that demand grew without the supporting training and regulating base. The Behavior Analyst Certification Board (BACB) is currently the only organization certifying behavior analysts internationally, meaning that only board-certified behavior analysts (BCBAs) are technically considered fully trained to deliver ABA services and provide coaching on service implementation.

Here is a random selection of numbers of active BCBAs available per some states and countries (bacb.org):

I selected at least one country from each part of the world and two states from across the United States, and the message is clear – there are not nearly enough trained service providers for in-person services. Could using telehealth help solve that?

There is no definitive answer yet, more research is needed. Based on what we already know, there’s a good chance that using telehealth for service delivery and training might be part of the solution. Right now the answer is more of a “maybe” than a “yes”. Sharing this message with a larger community and continuing to measure the effectiveness of various telehealth training programs and interventions nationally and globally will lead to having a larger body of research to rely on and more informed ABA service providers and consumers everywhere.

References:

Behavior Analyst Certification Board, http:/bacb.com/

Barkaia, Ana; Stokes, Trevor F.; Mikiashvili, Tamar (2017). Intercontinental telehealth coaching of therapists to improve verbalizations by children with autism. Journal of Applied Behavior Analysis, Volume 50 (3), 582-589.

Gerow, Stephanie; Radhakrishnan, Supriya; Davis, Tonya N.; Zambrano, Jacqueline; Avery, Suzannah; Cosottile, David W.; Exline, Emily (2021). Parent‐implemented brief functional analysis and treatment with coaching via telehealth. Journal of Applied Behavior Analysis, Volume 54 (1), 54-69.

Pollard, Joy S.; LeBlanc, Linda A.; Griffin, Christan A.; Baker, Joseph M. (2021). The effects of transition to technician‐delivered telehealth ABA treatment during the COVID‐19 crisis: A preliminary analysis. Journal of Applied Behavior Analysis, Volume 54 (1), 87-102.

Centers for Disease Control and Prevention, https://www.cdc.gov/ncbddd/autism/treatment.html

Prompting

Understanding and applying prompts is an important component of a Safety-Care trainer’s skillset. A prompt is a supplemental stimulus that guides the trainee to the correct response. When teaching any verbal or physical competency, a trainer may apply a variety of prompts, at different times, to promote errorless learning. Additionally, the prompt is a de-escalation strategy that helps an individual exhibit calmer, safer behavior that is different from the challenging behavior, and knowing different ways to prompt may enhance the application of this skill. I will discuss and share examples from both contexts for prompts: training Safety-Care and using The Prompt strategy.

Types of Prompts

There are two major categories for prompts: a response prompt, which acts on the response itself; and a stimulus prompt, which draws attention to the indicator preceding the response. (The indicator lets a person know that responding in a certain manner leads to reinforcement.)

Response Prompts

There are three major types of response prompts: Verbal instruction, Modeling, and Physical Guidance.

Verbal instructions are a common way to prompt the desired behavior by telling the trainee what to do (i.e., In elbow check, a trainer may say “I need you to bring your fingers together and come above the elbow.” While a verbal instruction in the prompt strategy may be, “sit down,” “take a deep breath.”). Sometimes we overutilize verbal instruction. Some individuals may not understand what is being said because they have never learned the instruction in the first place or language processing becomes difficult when escalated. Even in training, it may be easier to try another type of prompt because translating language into behavior can be challenging.

Modeling is best when the learner knows some of the skills. Sometimes we see trainers stand in view of the trainee and model the correct behavior (i.e., in Front Choke Release, when a trainer models bringing elbows up and pushing out, then over…). Modeling prompts can occur during de-escalation by modeling the incompatible or high-probability behavior. For example, if the staff person is trying to prompt deep breathing with a model, they will stay within view of the individual and take loud deep breaths, waiting for imitation. Be aware that for modeling to be an effective prompt, the learner must attend to the model and know how to imitate.

Physical guidance Is the most intrusive prompt. It offers the greatest chance at completing the procedure with the least errors because the trainer is moving the trainee to perform the behavior. A trainer may use physical guidance to gently move a trainee’s hands in the appropriate position for a procedure. Physical guidance can range from a light touch to moving a person/body part. Physical guidance can be used for the prompt strategy as well. For example, if an individual is laying on the ground and is uncooperative to move. A staff person may grab a chair and safely and gently place the individual’s hand on the chair to promote standing/ getting off the ground. However, it is important to note that an individual may become more escalated when touched and some regulating bodies consider physical prompts a restraint. Contact your clinicians or specialists if you are considering physical prompts in de-escalation. Generally, physical prompts may be more effective when the individual is calm and ready to learn.

Stimulus Prompts

There are three types of stimulus prompts: movement, position, redundancy.

A movement-based stimulus prompt occurs when we tap, touch, gesture. For example, when the trainer points to the area above the elbow when teaching the elbow check. We see this in the prompt strategy when a staff person points to a chair then the learner then sits down.

Position prompts increase the chance of responding correctly by using positional cues. For example, when the trainer is playing the individual trying to teach safety during physical management, they may bring their head closer to the trainee’s head to make sure they stay clear of head butts or bring their mouth closer to the trainee’s hand to stay clear of bites. These types of prompts can be highly effective because it highlights what are we trying to avoid, head-butts and bites. An example of a positional prompt for an escalated individual that usually de-escalates when told to squeeze a stress ball would be to place the ball closer to the individual.

Lastly, a redundancy prompt is when one or more response dimensions are paired with the correct response. When training Safety-Care this would be when the trainer is teaching the wait strategy and points out that a trainee should not be talking by spelling out WAIT as, “Why Am I Talking?” This may promote trainees to remember not to talk during this procedure. This prompt type is a little difficult to use in the context of escalation because it may require making materials beforehand (if you have some ideas for this one, please share!).

Prompting is an important tool for a Safety-Care Trainer and staff that work with individuals. To teach effectively, understanding types of prompts is critical because not everyone responds to the same type of prompt. Some learners find verbal instructions and models very effective, while others find physical guidance or positional prompts super helpful. Remember to apply your prompt before or during the response to promote errorless learning and try out these other types of prompts if you are having trouble inspiring independence in a skill.

Sources:

Cooper, J. O., Heron, T. E., & Heward, W. L. (2019). Applied Behavior Analysis (3rd Edition). Hoboken, NJ: Pearson Education.

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Interested in evidence-based behavioral safety and crisis prevention training? We’d love to learn more about your organization’s goals and how we can support your team with practical, compassionate, and proven strategies.